4 The role of ethics in plastic surgery

The subject of ethics pervades the specialty of plastic surgery. Ethical decisions are highly prevalent in its practitioners yet few realize they confront these choices regularly, almost daily. Behaving in a morally responsible fashion, maintaining high personal codes of conduct, and remaining competent in the operations is a noncognitive function for the vast majority of surgeons; it is deeply ingrained in the psyche. It also serves the surgeon well in presenting an overall highly regarded and deserved reputation amongst colleagues and the public.

Who to operate on and, more importantly, who not to operate on can in many instances be dilemmas that require moral choices. But many times the rationale is played out in the surgeon’s subconscious, one more decision out of dozens made daily, with just a few moments to evaluate the alternatives. Plastic surgeons do not go home to their spouses every night and claim they made a number of highly ethical choices today. Yet in reality the effects of not making the right choices can set up traps and entanglements. Breaching unwritten and written moral codes may bring consequences in this specialty. The harm may be done to others. The fallout is usually the surgeon’s predicament.

Consider this common scenario. A patient consults the plastic surgeon for a rhinoplasty, complaining of poor breathing and an old fracture. She also doesn’t like the shape of the tip of her nose. She claims she has no money for any private payment of the fees involved. But she also claims to have over a half-dozen friends who want their noses changed and states she will take them to meet the surgeon on each of her subsequent visits. The surgeon agrees to charge her insurance company for the entire procedure, hoping in the end to capture more business from the friendly and social patient, deciding it is a justifiable prevarication. Is this an ethical dilemma?

The moral issues of this story become a web of further entanglement when the insurance company suspects it paid for a portion of the surgery that was cosmetic and not functional. A few months later the patient receives a denial of payment from the company for what they have determined is the cosmetic portion of her anesthesia charges, the facility fee and surgeon’s fees. She is suddenly required to pay a sizable amount of money and in turn begs the surgeon to write off the balance since she still cannot afford to make up the difference.

Did the surgeon commit fraud? Was his decision to further his practice by committing a deception immoral? If he refuses to let the patient off the hook financially, will this affect his reputation with her friends who are by now signing up for their own surgery? Even if he made the very first decision that led to this predicament casually he cannot easily make this last choice without some degree of moral calculation.

Consider another situation. A 65-year-old uninsured diabetic is hit by a bus and suffers a compound tibia-fibula fracture and degloving injury of one-third of his lower leg. He is a smoker and is insulin-dependent. After the fracture is stabilized the plastic surgeon is asked to consult on the case for soft-tissue coverage of the sizable defect. Knowing that the zone of crush injury is extensive and there is compromised blood flow to the lower leg the surgeon must decide if a long and expensive operation with a modest but very real chance of being unsuccessful is worth the effort and cost. With an amputation below the knee the chances this man will ambulate in a prosthesis are good, but not guaranteed. Will prolonged recovery from a valiant limb salvage operation be the better choice? The surgeon knows he will not be reimbursed well for his efforts. His decision, if made on high standards, is based on what is right for the patient, not the surgeon.

These types of choices are encountered in similar situations on a daily basis by plastic surgeons all over the country. How one deals with these types of scenarios is multifactorial, complex and requires sophisticated decision trees. It is not immoral or unethical to say no in these situations.

Highly ethical persons have a well-developed internal moral code. They conduct themselves accordingly and believe that to do anything less would make them guilty of immorality. Contrast this with a sociopath who has no capacity for guilt, makes choices that he knows will deliberately harm others and then denies responsibility for the consequences. People living at the opposite extremes of this spectrum are rare. Most of us fall somewhere in between, the angel on one shoulder and the devil on the other.

Surgeons are themselves no different even though they have all supposedly taken the oath of Hippocrates to “above all else, do no harm.” The training of surgeons results in behavior that is consistent with the moral character of the role models the surgeon learned from, in both a positive effect and a negative one, sometimes full of awe, other times full of loathing. The behavioral end result of this training is a hybrid of choices, instincts, and internal codes that is rarely monolithic. More often the surgeon who has trained hard for a subspecialty designation is a complex, principled individual with a great capacity for a wide variety of mostly predictable and virtuous behaviors.

The specialty of medical ethics comprises a wide range of subjects that is considered valuable for physicians to consider and be knowledgeable about. It also takes into account the effects surgeons can have on society and vice versa. This includes controversial issues such as whether or not society should allow late-term abortions, death with dignity, or rationing of expensive treatments, to name a few. In general, the literature in medical ethics contains very little on the subject of plastic surgery.

In the lay literature, the ethics of having one’s appearance altered is a somewhat more common, but still rare, subject. Feminists weigh in on this topic most frequently, as do PhD candidates in the fields of sociology and behavioral psychology.^1–3 Yet these dialogues do not take into account the possibility that the surgeon has high moral standing. Instead the plastic surgeon is cast as a villain, forcing his or her susceptible patients into paying more than they can afford for quite frivolous reasons. The patients are defined as foolishly chasing an impossible-to-obtain god-like appearance, involuntary victims of society’s fascination with attractiveness. A further subtheme of these publications is the speculation that widespread alteration of homely persons into attractive ones will in the long term breed out common sense in our society.

The specialty journals in reconstructive or cosmetic surgery rarely, if ever, contain purely ethical articles of interest to the plastic surgeon.^4–6 There are, for now, no ethical courses one can take at medical symposia, and forums on the subject of ethical plastic surgery are unheard of.

Yet the fact remains that ethical decisions are quite common in the lives of plastic surgeons, in some cases occurring even on a daily basis.

Ethics as seen by professional associations

The American Society of Plastic Surgeons (ASPS), the largest membership organization in the specialty, was formed in 1935. The association’s attempt at a written Code of Ethics was first published in 1980. Members in good standing are expected to be familiar with this code and to adhere in their daily practice of surgery to the standards espoused within it. Failure to adhere to the guidelines can result in disciplinary action, including expulsion.

The expectations for ethical behavior on the part of members of the professional association are strongly worded and very specific. At times the code has been modified to meet new challenges such as those posed by the internet, charity raffles, and expert witness testimony. All realms of the specialty are covered within its dictums. The code also clearly spells out how a member will be dealt with if there is perceived to be a violation of the rules of the code.

Other members, patients, and lay persons can all lodge a written or verbal complaint with the ASPS Ethics Committee, stating what they think may be unethical behavior on the part of the member, actions that fall outside the proscriptions of the code. The member is then investigated by his or her peers and if it is decided that a violation did take place, the information is then passed along to the Judicial Council. The Council, comprised of members voted into that position, holds hearings to determine if sanctions should be placed on the member. Personal appearances before the Council are welcomed and the decisions made after a hearing are binding. Appeals of these decisions can be made to the Board of Trustees of the organization but are done infrequently. Plastic surgeons who are members of the American Society of Aesthetic Plastic Surgery (ASAPS) are subject to the same Code of Ethics and discipline. Members in good standing of both organizations may be elected to hold positions on the Ethics Committee and the Judicial Council for a period of 2–3 years.

Table 4.1 is a compilation of the data available from a review of the ASPS Ethics Committee’s activities over the 4 years from 2006 to 2009.

Table 4.1 American Society of Plastic Surgeons Ethics Committee’s activities, 2006–2009

While fewer complaints have been lodged lately, down to 81 in 2009 from 139 in 2006, the number of complaints that are reviewed after a committee investigation remained stable over this same period. Likewise the number of reviews that led to a hearing stayed at the same level, as did the number of hearings that resulted in disciplinary action.

Table 4.2

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