Written by Roman Gaehwiler
Reconstructive plastic surgery to correct ravages of disease and injuries as well as gross physical abnormalities constitutes a core medical practice. Reconstructive procedures, however, lie along a continuum, without any clear boundary between therapeutic reconstructive surgery for diagnosable problem and purely cosmetic surgery.[1]
In my mind, this excerpt out of a bioethics special section called “In Pursuit of Perfect People – The Ethics of Enhancement” reflects concisely what the current cosmetic surgery debate is all about. Nevertheless, I am not quite sure if such vague differentiations are capable to sustain a fruitful discussion towards a constructive conclusion. Particularly, the term ‘continuum’ rather summarises a historical development than a justification referring why we are obviously not able to distinguish between medicine and cosmetic surgery. In fact, modern aesthetic surgery has its origins in the medieval times, as disfigured faces of syphilis patients had to be reconstructed. Almost four hundred years later, during the 1880s, reconstructive surgery started to transform into a kind of operational method to serve ethnical assimilation of Irish immigrants in the United States. “Typical” Irish snub noses and stick-out ears had to be “denationalized” in order to be considered as American. As a result, the first face-lift could have been realised in 1901 by Eugen Hollander (himself surgeon and cultural-historian) who used to ease wrinkles of a female Polish aristocrat. Therefore, the so-called ‘continuum’ might rather fit a historical context, otherwise there would be no necessity to classify aesthetic interventions into reconstructive, plastic or even cosmetic surgery nowadays. Within the following listing I will try to reveal the obvious lack of medical traits in cosmetic surgery. Consequently, it may be in the interest of medicine itself regard cosmetic surgery as a non-medical supply of services.
1. Medicine is definable
Medicine is the practical appliance of medical sciences including physiology, biochemistry, physics, psychology or anatomy in order to support humans (and animals as well) recovering from pathological states and diseases. Therefore, the ultimate goal of medical treatment is neither to provide happiness nor joy. Such outcomes represent just a positive side-effect of a successful medical intervention while restoring someone to a worth living existence. I deliberately do not make use of the term health, because health implies full functioning of the human body. A medical measurement might also be interpreted as ‘successful’ if a diabetic is able to enjoy positive effects by the administration of insulin, even though his pancreas is still not capable to produce enough insulin itself. In contrast, cosmetic surgery aims just to lift somebody from a subjective unhappy into a subjective happy state without reconstructing any functional misbalance. As a consequence, if the assistance of a transformation from unlucky to lucky, ugly to beautiful or even shy to self-conscious allows you to call yourself a medical professional every Bentley car-salesman may be eligible for a doctor-degree, as well.
2. Medicine acts objectively
The definition above involves reconstructive and plastic surgery as a surgical alteration of objective aesthetic abnormalities. By contrast, cosmetic surgery merely feeds one’s subjective appetite for individual enhancement. In fact, objectivity is an important medical trait in order to legitimise certain measures in social frameworks like health-care-systems. So, real medical interventions are financially and socially defensible whereas cosmetic alteration founds on a self-payer basis. Regarding this, cosmetic surgery lacks a very important medical component and disqualifies itself to be seen as a part of real medical environment.
3. Cosmetic surgery suggests disease
The suggestion of physical insufficiencies or even exploitation of sore points reveals most obvious within the advertising policy of cosmetic surgeons.
The role of physician as salesman is displayed by the frequent offer in cosmetic surgery ads of free consultations, often with the aid of computer imaging. Targeted at women, these ads play on, and possibly contribute to, widespread dissatisfaction with body image and foster unrealistic expectations of what can be achieved by cosmetic surgery. Moreover, they give no indication of risks or complications from cosmetic surgery or the chance of less than fully satisfying outcomes (p. 360).
In this concern, cosmetic surgery might also be seen as deliberate creation of disease. Almost superfluous to mention that such kind of advertisement lacks of ethical or even moral considerations regarding a ‘patient’s’ mind (maybe I would be more precise by using the term ‘customer’) and is therefore completely antithetic to what medical doctors take a Hippocratic oath on. Furthermore, undermining patient’s self-consciousness may presumably not be accepted as a common medical strategy in order to become healthier.
4. Moral degeneration of medical ethics
In my opinion, that is probably the most important issue in the course of this argumentation. Regarding cosmetic surgery as a legal part of medicine would imply a certain degeneration of medical ideals and values. Especially, the striving to financial benefit by the common aid of advertisement and propaganda misses altruistic and transparent behaviour as two of the medical ideals. In no other discipline medical professionals are able to influence the outcome of their treatment such like within cosmetic surgery. Many cosmetic surgeons regard themselves as a kind of artist holding the privilege to create something extraordinary out of a healthy human body. In my opinion, the so-called “art of medicine” is actually to be able to transform scientific knowledge into practical appliance rather than praising the creator of a visible result. Medicine is less about personality cult or even image cultivation it is more about altruism and moral responsibility. To fulfil such social standards every day might be hard, but that is actually the legitimation or even the price you have to pay to come a little bit closer to what the definition of medicine is all about.
Nevertheless, I have to admit that there is at least one medical trait which is especially well pronounced in cosmetic surgery, namely the centralisation of patient’s self-esteem and individual interest. As Brasilian surgeon Ivo Pitanguy uses to explain it: “Plastic surgery is exercised democracy.”
To come to a conclusion, cosmetic surgery does not represent a social problem. Whoever decides to undergo surgical procedures in order to enhance his/her appearance instead of normalising it should absolutely not be prohibited to go for it. Everything else would affect the human right of individual freedom. As a consequence, I would like to emphasise that I do not reject cosmetic interventions at all, admittedly it is a really good business idea, BUT I strongly do reject the promotion of such businesses on behalf of “medical treatment”. This would be hypocritical and deceptive. Cosmetic surgery acts among the ‘supply and demand’ ideology of Adam Smith (1723-1790) and not among the ‘medical-ethos’ of Hippocrates (460-370 B.C.). We can be thankful for both, but we might have to be aware of mixing it.
[1] Cosmetic Surgery and the Internal Morality of Medicine. Franklin G. Miller, Howard Brody, and Kevin C. Chung, Cambridge Quarterly of Healthcare Ethics (2000), 9, 353-364 (Cambridge University Press)
Roman,
There is a lot in this article that screams for a response and I will probably spread my comments over several instances so as to give me time to digest everything more fully.
To start, however, I would question what you mean by the following:
“Therefore, the ultimate goal of medical treatment is neither to provide happiness nor joy. Such outcomes represent just a positive side-effect of a successful medical intervention while restoring someone to a worth living existence.”
In particular I would very much like to hear how you can so radically separate “happiness or joy” from “a worth living experience.” Surely you do not mean that an existence devoid of happiness and joy is worthwhile? Surely you do not mean to say that the happiness and joy felt by patients cured from an aggressive tumor, the meaning and the reason to live that they have been gifted back by the clinical team, is “just a positive side-effect of a successful medical intervention”? For if you do, I would have to contend your view of medicine is dangerously shallow and wholly inaccurate. Such a medicine is disquietingly inhuman.
To my mind a lot is hinged on what you mean by “the ultimate goal.” If by this you mean the exclusive and over-riding, then I’m afraid you are simply wrong. Other values and considerations are clearly relevant and significant in decisions about medical treatment. If, on the other hand, by “ultimate goal” you mean that it is a value that is especially weighty and deserves of special attention, then your choice of words is a poor one and, more importantly, your main argument is undermined. If getting back to a non-pathological state is simply one goal among several, then it is an open question as to whether or not it is to be the guiding or decisive goal, overriding considerations of subjective wellbeing.
You have provided no argument along these lines and simply assumed either (1) getting rid of pathology is the sole and exclusive value of medicine, which is false, or (2) that non-pathology is a decisive value among others, which you have not defended.
Second, your claim that “Medicine acts objectively” seems in contrast with the very subjective and relativistic nature of the history of medicine, as it has been expounded by medical historians and sociologists. On the topic of cosmetic surgery and aesthetics, not so long ago being black was considered a kind of disease in America and considerable efforts were put into bringing the black man to the non-pathological state of whiteness. I do not raise this point as a way of introducing the “trump card” that is racism. Rather, it is a point about the very contentious claim that there can be such things as objective aesthetic abnormalities. Indeed, a less forceful but still significant challenge is in what would the demarcation between objective and subject aesthetic abnormalities look like.
Where exactly is the line to be drawn? Having a disfiguring face burn, perhaps? But surely so long as their is no risk of infection or complications the only reason left to do a corrective skin graft is to make the appearance more acceptable to others. But this is not objective, it is merely a reflection of the subjective repulsion of other to the way one looks. Had we simply not treated those with severe burns differently, there would be no need for corrective surgery. Subjectivity abounds.
Finally, I am puzzled by what you mean to say by claiming that cosmetic surgery is not a medical treatment. In particular, I am still unclear as to which part of “medical treatment” is most incompatible with cosmetic surgery. Is it the “medical”? But surely anything that involved “surgery” ought to count as medical? Perhaps the tension is more alive between “cosmetic” and “treatment”? But here I would be very skeptical of your definition of treatment as completely devoid of considerations of the subjective state of the patient and I am not sure that an objective aesthetics can carry the weight here.
You may have more purchase if you were to couch this in terms of treatment (specifically corrective treatment) as opposed to enhancement. Although I suspect that that route is similarly littered with obstacles and objections.
Dmitri, thank you very much for your comment, I really appreciate this kind of discussion because it reveals what cosmetic surgery obviously lacks, namely a clear and unmistakable definition.
First, in my blog I tried to distinguish between reconstructive, plastic, and cosmetic surgery. Even if it might be a repetition I think it’s essential to have a common basis while talking about cosmetic surgery otherwise it may lead into misapprehensions. Therefore, in my opinion, reconstructive surgery implies a regeneration of function, as well as a reconstruction of the former state (as good as possible). You mentioned the burned face, but that is definitely a specific example for reconstructive surgery. Plastic surgery represents a kind of link between reconstructive and cosmetic surgery because the reconstruction of a certain function is not essential in plastic surgery. Even more it is about the correction of an objective (I’ll explain my understanding of this term later on) aesthetic blemish. In my blog I tried to emphasise this by noting the stick-out ears. Actually, ear-correction is one main aesthetic intervention on children conducted by plastic surgeons. Finally, there is cosmetic surgery which neither reconstructs a function nor corrects an objective severe physical abnormality. In this respect, I regard ‘objectivity’ and ‘normality’ as two terms which are very strongly related. Therefore, I would define ‘normal’ as what approximately ninety persons out of hundred would declare as ‘averaged appearance’ or even as ‘neutral beauty’. That is also what my “demarcation between objective and subject aesthetic abnormalities look like”. In other words, for me it’s the subjectivity of a big majority which creates objectivity. Regarding this, a person who undergoes a face-lift or injections of certain doses of botulinus toxin in order to ease wrinkles, although he/she still might be interpreted as “attractive” by ninety individuals out of a cohort of hundred (= objective rating), may just enhance his appearance in order to gain social advantages or subjective contentedness. Surely, there is no objection against that from an economical or even social point of view (that’s an individual decision), but lifting someone above others is not what the Hippocratic-Oath stands for and therefore, in my mind, not worth to achieve medically.
Second, you wondered how I can so radically separate “happiness and joy” from “a worth living existence” (I suppose you mean existence when writing experience, because I never wrote something about experience in this concern?). Of course I do not regard an unhappy state as not worth living, that’s definitely not the message I had in mind while writing this phrase. Nevertheless, what I do regard as absolutely essential (especially in terms of medicine) is the distinction between ‘happiness/joy’ and the potential outcome of a medical treatment. In my opinion, every human being is responsible to create his individual life happy and joyful for itself. Everything else would represent a shift of responsibility and in the case of medicine an inaccurate (and surely unfair) expectation of your individual physician’s duty. A medical doctor got the knowledge how to recover a patient from a pathological state, but he is certainly not responsible for the happiness and joy in his patient’s life. Otherwise you could also held the vender at McDonald’s responsible for you getting over-weighted. You state that “such a medicine is disquietingly inhuman”. I would rather say that letting your personal physician carry the burden of YOUR individual happiness might be inhuman. In this concern, I would still stick to my principles regarding your example with the tumor-patient. If a cancer patient after months or even years of chemotherapy (which usually includes suffering from alopecia, fatigue, weakness, nausea and various other side-effects) is still able to enjoy his life I would definitely call that a positive (and of course from a medical perspective desirable) side-effect. In this case, maybe ‘outcome’ might be a better term. Nevertheless, regarding life as ‘worth living’ after facing such tortures requires strong psychological capabilities and abilities of the patient himself. These individual traits may optimize the outcome of a medical treatment, but they do not represent a predictable component of a treatment strategy. In fact, hair-loss, vomiting and feeling miserable represent a kind of proof whether medical intervention starts working, but it is presumably not considered as ‘a happy and thankful state’ from a patient’s point of view (although medical treatment is defined as being ‘successful’).
Third, the “ultimate goal” was meant to imply that there are several aims which might be achievable within a treatment strategy, but there is only one goal you have to reach implicitly. As a doctor, happiness or joy might/should be part of your thoughts while planning a treatment strategy, but must not get the same importance as solving the real problem, namely recovering the pathologic state of your patient. To emphasise this with the aid of an example; a psychiatrist, who tries to work out the bad memories of a woman who used to be a victim of repeated sexual abuse, encourages his patient to be able to handle her past in order to be able to enjoy a future sexual relationship. Instantaneously, such a treatment does not provide happiness, but it equips this specific woman to cope with her future feelings, thoughts and memories in this concern.
Roman,
Thank you for some needed clarifications. Nevertheless, I must say I remain somewhat puzzled by your positions.
To start, you put a lot of stock in the Hippocratic Oath. In particular you make a very interesting claim that the Oath does not stand for improving other above their natural function, it does not stand for lifting people above others. However, I would be very interested to know where in the Oath you find a justification for this claim. To my knowledge nothing therein speaks to preventing a physician making his patient better than he would have been otherwise.
The modern interpretation of the Hippocratic Oath (http://www.pbs.org/wgbh/nova/doctors/oath_modern.html) does not seem very supportive of your claim.
I would be interested to hear your justification.
On another point, it is interesting that you employ the notion of functioning as a criterion for legitimacy of medical procedures. I assume you have in mind something like the notion of normal species functioning employed by the philosopher Norman Daniels, or something closely related. As attractive as this notion is, however, it is not without problems. To start, it is far from obvious as what a satisfactory definition of normal function would look like. Accounts have been proposed but remain, to my knowledge, hotly disputed. And yet you would need a stable account of normal functioning to even begin to define what regeneration or restoration of function could mean.
On a related point, I would ask on what grounds you would justify making restoration of an assumed normal state the exclusive definition of medical treatment. This dips into the debate over treatment vs. enhancement. Your general position, as far as I can read it, is that medicine is properly charged with keeping people healthy, ie at or within the normal range of functioning. But it is an open question from that as to whether that is all that medicine ought to be concerned about. Why should it not be within the legitimate domain of a medical doctor to improve his patients, given the standard procedures for treatment (informed consent, benefit/harm ratio, etc.) are satisfied? From what I can tell you position teeters on the brink of outright forbidding of procedures like cosmetic surgery and other forms of enhancement. But where is the justification for this? If it is in the Hippocratic Oath, as you seem to imply, I am skeptical if it bears the burden successfully.
Lastly, I would respond on the points about joy and happiness in relation to worthwhile existence and goals of medicine. It was never my claim that the physician should carry the burden of the happiness of his patients. This claim is far too strong. My point was that it seems very likely that at the very least a physician ought have the joy and happiness of his patients as relevant considerations in his practice, something you seem to endorse. My point was not about responsibility as such, rather it was about what considerations are relevant in medical practice.
I agree that a trained doctor receives highly specialized knowledge on how to return the body from a pathological state to a range of normal functioning. My point was what this knowledge ought to be used with the happiness and joy of the patients on whom the procedures are to be performed clearly in mind. My reference to inhumanity can be restated as follows: A doctor who returns a patient to his normal range of functioning for no other reason than removing a pathology is practicing a kind of inhuman (perhaps a less charged term would be ahuman, in terms of absence of human qualities) medicine. A key reason that should be present before the doctors mind is that this will improve the wellbeing of the patient, that is the reason for the procedure. As such I do not see a way of divorcing so radically the notions of happiness and treatment as you seem to suggest.
Dmitri,nice and challenging comments are worth to be discussed 🙂
My claim is based on an interpretation published by the emigrated German philosopher Ludwig Edelstein of John Hopkins University. I have to admit that his version represents a classic English translation of the Hippocratic-Oath and not a modern one as you recommended (but actually it doesn’t matter at all). In his version it says: “I will apply dietic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.” The term which attracted my interest was indeed ‘injustice’. As I mentioned in the blog I do regard cosmetic surgery as a kind of enhancing method. Furthermore, I suggested that ‘enhancement’ is (in my opinion) not in harmony with the principles of medical ethics. The explanation for this, is based on the fact that the funding of medical treatment in most industrialised countries is provided by a medical health-care system. This system represents financial support within a social framework, realised and fed by the regular payment of insurance rates. Concretely, a wonderful system where everybody helps each other in order to enable the sick being capable to afford expensive and inevitably needful medical treatment. To make a long derivation short. Cosmetic surgery (or even enhancing treatment?) is based on a self-payer policy, BUT in case of a complication (infections or complications which appear maybe months/years after the operation itself) the insurance-company (and therefore society) may be held responsible for the financing of these complications. In my opinion, this would be a highly inequitable way to deal with people’s money and undermines the idea of social responsibility and respectfulness. Making a “financial-distinction” between cosmetic surgery and its complications would mean to satisfy subjective requirements with the aid of society’s good faith. Finally, that is what I regard as unjust and, therefore, as an “offence” against the requirements of the sick and simultaneously the Hippocratic-Oath. Accepting such policies would mean to regard some people’s desires, in order to improve their look, as ‘above’ or rather more important than the general health of a community.
This justification would also be my response to your question: “Why should it not be within the legitimate domain of a medical doctor to improve his patients, given the standard procedures for treatment are satisfied?” Even the “standard procedures” are not free of charge. Therefore, as long as you regard subjective improvement as an aspect of medical treatment I would still refuse to interpret this as a medical necessity which has to be financially carried by the community. In my opinion, medical treatment represents a social service, based on the social interest of general welfare and health and not a self-service store.
In respect to your last point (“divorcing so radically the notions of happiness and treatment”), I would like to emphasise again that I regard such a radical distinction as a necessity in order to protect the medical professional from unrealistic expectations (which actually represent a specific problem within cosmetic surgery). Furthermore, I think by defining a term like “the ultimate goal” (which includes a sense of ‘radicality’, as well), you have to stay consequent (= radical), even in the distinction of happiness and treatment. Nevertheless, in this concern a clear distinction does not exclude connections because ‘ultimate’ has been used within a chronological context and not as a general rule.
Roman,
I had the feeling that it was injustice that was at the heart of your position. However, I am not quite clear how cosmetic surgery is necessarily unjust, much less what that has to do with it being within the category of medical treatments proper.
You base your argument on the observation, a correct one, that health care systems cover medical treatments that are best described as returning patients to normal level of functioning. I agree, and this how it should be, particularly when pooled resources such as in public healthcare or pooled insurance coverage. There is a clear difference between my dollars going towards returning someone to normal functioning and my dollars going towards extending the range of functioning beyond the normal. Enhancements ought to and for the most part are paid for out of pocket.
So if your claim is that paying for someone’s cosmetic surgery out of shared resources is unjust, I fully agree. However, that does not make the procedure itself unjust. It is not unjust, for example, for me to spend my own resources to enhance my looks. Furthermore, and closer to the meat of the argument at hand, I do not see how this has any relevance with regard to cosmetic surgery being within the category of medical treatments.
Health care funding is generally extended to those medical procedures that return the patient to normal level of functioning. This does not, however, serve as an exclusive condition on the definition of medical treatments. There is a distinction that is made between treatment that restores health, therapeutic treatment, and treatment that enhances, enhancing treatment. I do not see how the question of who pays for what has any say in making medical treatment exclusively therapeutic.
You make an interesting point about complication that may accompany cosmetic surgery. I am not up to speed on the financial aspects of these procedures, but I would suspect that complications are addressed in the payment structure and the performing surgeon has liability insurance to cover for many of such consequences. As such I do not see much purchase to be found in pinning the wrong of cosmetic surgery on siphoning off public resources by adding burdens of restoring botched surgeries.
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