Ethical Considerations in Cosmetic Surgery



Ethical Considerations in Cosmetic Surgery


Alice M. Laneader MBe

Paul Root Wolpe PhD



Altering human physical appearance is as old as recorded history. Tribal people pierce, scarify, stretch, distort, deform, tattoo, file, and remove body parts in pursuit of the beauty standards of their cultures. Similar, if not identical, behaviors are found in Westernized cultures. As detailed in Chapter 3, evolutionary psychologists have linked our desire for altering the body to innate biological drives of partner selection and reproduction. In one sense, cosmetic surgery is the application of our best technology to the aesthetic standards of modern American folk culture, no different in principle from lip plates and neck rings found in other cultures throughout the world.

We currently stand at a unique point in the history of such practices. Our unprecedented ability to manipulate human physiognomy raises new questions about the nature and limits of altering the body for purposes other than curing disease. Advances such as human reproductive cloning, genetic engineering, prosthetic organs, and brain-computer interfaces are fundamentally changing what we mean by human enhancement. These advances force us to consider the extent to which we are willing to reshape ourselves, and what changes, under which conditions, will be considered acceptable (1). Cosmetic surgery, thus, serves a harbinger of our attitudes toward a host of other technologies.

Bioethical analysis of cosmetic surgery considers a number of other problematic elements as well. Critics question the ethics of undergoing surgical risk to alter appearance rather than to cure infirmity. Many modern procedures, particularly those developed in the last decade, lack a sufficient body of evidence from clinical trials to support their efficacy and safety (2, 3). Risk to patients is further increased as procedures become more ambitious and patients are placed under anesthesia for longer periods of time during the course of multiple procedures. Furthermore, there is little consideration, let alone consensus, in the field as to the differences between surgical experimentation, surgical innovation, and accepted standards of practice (2, 3).

In addition to medical objections, many critics are concerned with the social and cultural aspects of cosmetic surgery. By pursuing some cultural ideal of beauty, they argue, cosmetic surgery is complicit with social messages of inadequacy, of need to conform, and of the blurring of the individual in relationship to the larger social group (4, 5, 6). Pursuing media-generated ideals of beauty, cosmetic surgery, critics argue, contributes to the oppression of women and minority groups (4,7, 8). The issue brings up questions of medicine’s role in perpetuating, or at least cooperating with, oppressive stereotypes, as well as the degree to which cosmetic surgery, as a medical enterprise, should resist or cater to consumer desires (8).

The field of bioethics tries to identify, edify, and make prescriptive judgments about ethical issues in medicine. In so doing, it draws upon a history of philosophical analysis of ethical principles, case studies, empirical research, and historical precedent. Bioethical dilemmas are often conceptualized upon foundational principles such as respect for autonomy, beneficence, non-maleficence, and justice. For
example, the Hippocratic Oath states: “I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice,” which emphasize the duties of beneficence and non-maleficence (9). The modern American Medical Association Council on Ethical and Judicial Affairs’s “Fundamental Elements of the Patient-Physician Relationship,” as well as the American Nurses Association’s “Code for Nurses,” both discuss the respect for human dignity drawing on principles of autonomy and justice (9). The role of bioethics is to examine medical practice, the social and cultural medical environments, and emerging medical technologies to illuminate and critique the kinds of ethical principles on which they are based and the practices they pursue.

In this chapter, we will consider the ethical challenges of cosmetic surgery. In the first section, we will examine a number of basic bioethical constructs and apply them to cosmetic surgery; we will examine the enhancement versus therapy debate, risk, patient autonomy, beneficence, and informed consent. In the second section, we will examine the social and cultural challenges that cosmetic surgery poses.


BIOETHICAL CONSTRUCTS AND COSMETIC SURGERY


Enhancement Versus Therapy

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.


Beneficence and Non-maleficence

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.


Autonomy

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

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):



  • What are the indications that have led your doctor to the opinion that an operation is necessary?


  • What, if any, alternative treatments are available for your condition?


  • What will be the likely result if you don’t have the operation?


  • What are the basic procedures involved in the operation?


  • What are the risks?


  • How is the operation expected to improve your health or quality of life?


  • Is hospitalization necessary and, if so, how long can you expect to be hospitalized?


  • What can you expect during your recovery period?


  • When can you expect to resume normal activities?


  • Are there likely to be residual effects from the operation?

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.

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Sep 12, 2016 | Posted by in Reconstructive microsurgery | Comments Off on Ethical Considerations in Cosmetic Surgery
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