The Ethics of Cosmetic Surgery

 

 

Advances in plastic and reconstructive surgery have revolutionised the management of patients suffering from disfiguring congenital abnormalities, burns and skin cancers. Aesthetic (or cosmetic) surgery refers to plastic surgery performed to improve physical appearance in the absence of pathology. The demand for aesthetic surgery has increased in recent years as our culture has become more concerned with image and appearance.

 

Many regard aesthetic surgery as a panacea for their personal and relationship difficulties. This may reflect modern image-obsessed popular culture, but it can be due to deep-rooted insecurities. Body Dysmorphic Disorder (BDB) is a psychiatric syndrome, characterised by a pre-occupation with a non-existent or minimal cosmetic "defect" associated with persistent attempts to have the defect surgically corrected. BDB is increasingly recognised, and may be becoming more prevalent.

 

In the National Health Service (NHS), finite resources limit the availability of aesthetic surgery to those who suffer significant psychological distress due to their appearance. In the independent healthcare sector, aesthetic surgery has increased in popularity, reflecting increased consumer demand.

 

In 1979, Beauchamp and Childress published Principles of Biomedical Ethics, in which they presented four "principles" that have since been adopted as the ethical basis for contemporary UK medical practice. They argued that these principles "bridged" high-level moral theory and what they described as "low-level common morality". These principles included: respect for autonomy, beneficience, non-maleficience and justice. Whilst these principles were developed to guide physicians treating those suffering ill health, they provide the ethical framework which underpins modern surgical practice.

 

Respect for Patient autonomy

 

In general, competent adults have the right to decide whether they wish to undergo a surgical procedure. Providing they are given sufficient information, on which to make an informed decision, patients' wishes must be respected. Information must include the risks of surgery together with alternative options. These principles still apply to aesthetic surgery where patients are not suffering from an "illness".

 

Beneficience

 

This principle requires medical practitioners to act in patients "best interests". Undertaking surgery to improve a patients self-image and esteem is acceptable. However, defining patients best interests can be very difficult. Many people experience real pain, discomfort, social handicap and suffering because they are self-conscious about their appearance. This group benefit from aesthetic surgery.

 

Non-maleficience

 

This principle ensures that doctors never act against patients' best interests or in a way that may harm a patient. Consultant plastic surgeons may decline to operate on patients if they do not believe that surgery is in patients' interests. Surgeons are reluctant to operate on those with unrealistic expectations, as the risks of surgery may outweigh any benefits. Patients with serious health problems are at increased risk of suffering complications under general anaesthesia, and again the risks may outweigh the benefits. All such assessments need to be made on an individual basis. In the past, there has been a perception that surgeons have a potential conflict of interest in the independent sector. No surgeon would ever proceed with an operation merely for personal pecuniary gain. All surgeons take their duty of care to their patients very seriously.

 

Justice

 

This principle requires doctors to ensure that medical care to available to all. Equitable access to healthcare is regarded as a basic human right. However, resources are limited and it is not possible for the National Health Service to provide aesthetic surgery for all those who would like it. "Rationing" takes place on the basis of clinical need. Inevitably, this introduces subjective judgments about whose need is greater. In the private sector, those who can afford to pay can undergo surgery.

 

 

 

With appropriate patient selection, aesthetic surgery can offer excellent cosmetic results. Patients must undergo thorough pre-operative assessment and counseling before surgery. This may require expert psychological assessment. Surgeons must ensure that patients' expectations are realistic. Surgeons need to explain the likely benefits of surgery, alternative non-surgical options as well as the risks of surgery and anaesthesia. Patients need to make an informed choice regarding whether surgery is right for them. Consultant surgeons and consultant anaesthetists treating patients, undergoing cosmetic procedures, should be on the General Medical Councils' Specialist Register. Surgery should only be undertaken in premises that are fully-equipped, with resuscitation facilities and staff trained in advanced life support. Clinics and hospitals providing aesthetic surgery should be registered with the Healthcare Commission.

 

 

For further information:

 

The British Association of Aesthetic Plastic Surgeons

www.baaps.org.uk

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References

 

Beauchamp and Childress, Principles of Biomedical Ethics, Fourth Edition.

Oxford. 1979