Ethics and Plastic Surgery Practice

Kenneth W. Goodman and David J. Birnbach

Biomedical ethics guide physicians in making the challenging moral decisions associated with delivering appropriate health care. Each specialty has a unique set of ethical issues, yet they all follow one or more guiding frameworks for contemporary medical practice.1 In this chapter, we address the complexities of biomedical ethics specifically associated with the practice of plastic surgery. Fields of medicine associated with aesthetics are being fueled by increased consumer demand, in part because of the effects of the media and a society that is greatly concerned with image and appearance.² The specialty of plastic surgery requires a particularly mindful approach so that professionalism and the physician–patient relationship are held in high regard and the patient is free from exploitation. Unlike many other physicians, plastic surgeons can provide aesthetic changes or other physical alterations that may be deemed unnecessary for proper physiologic function. Furthermore, there is a level of subjectivity involved in the decisions related to whether plastic surgery should be provided. These issues are the focus of this discussion.

In general, biomedical ethics can be defined as the study of morality in medicine, and this morality concerns both character and behavior.³ One guiding framework for contemporary medical practice has been crafted as four principles bridging low-level morality with high-level morality. Published in the Principles of Biomedical Ethics, Beauchamp and Childress³ established respect for autonomy, beneficence, nonmaleficence, and justice as the core values underpinning modern medical and surgical practice.

Respect for autonomy is reflected in medical practice through the consent process. This is not merely obtained by just getting a signature on a preprinted form; the surgeon must explain all the associated risks of surgery, particularly when, as in plastic surgery, the patient is not necessarily experiencing an illness. Beneficence-based clinical judgment identifies the moral obligation to act in the best interest of the patient.⁴ This is complex in plastic surgery, where iden tifying the best interest is often a subjective determination. Nonmaleficence protects the patient from harm and negligence. In plastic surgery, the challenge may lie in a patient’s expectations or complications, sometimes because of existing medical conditions. The concept of justice requires that access to care be equitable. Because most aesthetic procedures are elective, the ability to pay and the sale of services is an especially complex matter.

A surgeon who repairs a cleft lip, performs postmastectomy reconstruction, or restores craniofacial structures after an accident may be confident that he or she is eliminating a defect or restoring a body part to a baseline level of function or appearance. These types of reconstructive surgery raise the typical ethical issues related to access, consent, and the surgeon–patient relationship. On the other hand, cosmetic surgery has as its primary ethical challenge the fact that such service may not be accessible to all patients because of economic, social, or geographic limitations. In these cases, an unfavorable outcome is typically limited to incomplete restoration of function, increased pain, infection, or physician error. Although the results may not be as aesthetically appealing as the patient expected, they will typically be an improvement over the presurgical appearance.

On the other hand, plastic surgeons who perform the more common elective surgeries such as blepharoplasty, rhytidectomy, rhinoplasty, abdominoplasty, augmentation mammoplasty, or body contouring procedures (to name a few) may be doing so to improve a patient’s sense of personal aesthetics. Although there may be an unfavorable result or some form of error that impairs a function or degrades an appearance, an ethical and reputable plastic surgeon will engage in conversations with the patient regarding the potential risks and will receive informed consent.

In considering the use of plastic surgery as a panacea for personal and relationship issues or other social pressures, the plastic surgeon may face an ethical dilemma. Therefore these patients should undergo a very thorough preoperative assessment.3 Ultimately, however, if the patient has been properly evaluated and provides a solid rationale (even if it is just to look better), the plastic surgeon has fulfilled the ethical obligation.

Ethical Foundations and Practical Tools

The foundations of full disclosure and valid consent can be especially challenging in plastic surgery. Valid consent entails three components (Box 4.1).

These criteria evolved over decades of debate and analysis regarding human subject research and clinical practice. They are universally accepted and have come to shape the laws governing research and practice. This is as it should be; ethics precedes the law to establish the criteria legislators use in determining what behaviors are permitted, required, or forbidden. The three criteria for valid consent are jointly required: It would be a mistake to regard the consent process as valid if one were to inform an incapacitated patient of risks, benefits, and alternatives or to allow a family member to exert undue pressure on an informed and capacitated patient. For this reason, the term “valid consent” is preferable by many to “informed consent,” which highlights only one of the three criteria; indeed, the lack of capacity or voluntariness invalidates the consent of a patient who has received adequate information. Note also that these are the same criteria for “valid refusal,” such that if a capacitated, informed, and free-acting patient refuses treatment, that refusal should generally be honored.

The literature on each of these three criteria is vast and analyzes best practices in the event of failure of any of the three criteria. Generally, if a patient has received inadequate information, the surgeon should communicate better and ensure that such communication is part of a process and not a single event that concludes with the signing of a legal consent document; if a patient is being pressured or coerced into receiving or refusing a procedure, the surgeon must reassure the patient that the choice is his or hers and try to assist in eliminating the source of the inducement; and, if a patient lacks capacity, either functionally or by legal criteria, the surgeon must seek the help of a surrogate or proxy.

Box 4.1 Three Components of Consent

1. Adequate information so a typical patient can make a reasoned decision whether to proceed

2. Cognitive capacity or, generally, the ability to understand and appreciate that information

3. Voluntariness, or freedom from beguilement, undue pressure, or even coercion

This last is often the most difficult to manage, and it is especially tricky in the case of cosmetic procedures. In ordinary, nonemergency reconstructive procedures, the consent process is usually straightforward. The surgeon informs the patient of known risks, anticipated benefits, and alternative procedures; highlights anything distinctive about the procedure or the products to be used (the use of fillers or dressings with biological materials—i.e., synthetic mesh); and makes it easy for the patient to ask questions. In both noncosmetic and cosmetic procedures, there are two overarching challenges: Demonstration of technical proficiency to the best of one’s ability and patient satisfaction with the resulting appearance. Assuming the surgeon’s proficiency, a lack of error, and the fact that the valid consent process was clear about risks, the patient may have few options if the desired result is not achieved, except perhaps a corrective procedure.

In both cosmetic and noncosmetic cases, however, patient dissatisfaction regarding aesthetics is much more difficult to address and manage. In cosmetic surgery, the challenge of such dissatisfaction rises to an extraordinary level—so much so that in seeking to prevent “unfavorable results,” the tools and requirements of valid consent are stretched to the limit; indeed, in some cases, the consent process may not be up to the task. There are two reasons for this. The first is that the procedure was not medically necessary in the first place. The second is unrealistic expectations; in some cases, even patients with adequate capacity to consent to surgery have very poor insight.

Cosmetic surgery has long posed ethical challenges and indeed been subjected to criticism and sometimes regarded as a peripheral medical practice 5:

Although increasingly popular, cosmetic surgery is a most unusual medical practice. Invasive surgical operations performed on healthy bodies for the sake of improving appearance lie far outside the core domain of medicine as a profession dedicated to saving lives, healing, and promoting health. These cosmetic procedures are not medically indicated for a diagnosable medical condition. Yet they pose risks, cause side effects, and are subject to complications …

This negative perception of elective aesthetic surgery has been blamed in part on the media and the “flashy” behavior of some aesthetic plastic surgeons.⁶ Nonetheless, many plastic surgeons enjoy favorable reputations and stake their professional name on building good relationships with patients and performing appropriate surgeries as determined by the surgeon with their patient. In the end, the work of a plastic surgeon is in plain sight, so surgeons serve their own self-interest by governing themselves accordingly.

Even with a comprehensive disclosure of surgical risks—including the possibility of aesthetic disappointment—as part of the valid consent process, some patients will be dissatisfied. Most cosmetic surgeons have had the experience of performing a near-perfect rhinoplasty or breast augmentation but nonetheless ultimately having a disappointed patient. Such frustrations can in principle be mitigated or reduced by careful preoperative discussions 7 (Box 4.2).

Box 4.2 Preoperative Discussion

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