Jennifer is a thirty-two-year-old single competent female who has transformed her body over the last decade, from a stick-like Plain Jane to a voluptuous Valkyrie. She has had liposuction, breast implants, facial surgery, and to refine her new body, used drugs, exercise, and diet. While previously hating her body, she now displays it by wearing revealing outfits. When people glance at her, she basks in their attention.
Is there anything wrong with Jennifer? With what thousands of other women like her want to do? If something has gone bad with Jennifer, is it a moral matter or just one of different personal values? Is what Jennifer has done enhancement or disfigurement? How do we know the difference? Should society encourage or discourage such changes?
For some philosophers, what Jennifer has done is not a moral issue and cannot be. After all, it's her body, her life, and what she does with it has little chance of harming others.
Alas, as a century of scholarship on On Liberty has taught us, the distinction between self-regarding and other-regarding actions is not a sharp one. If some women start to enlarge their breasts or have facelifts, it affects the norm and how other women feel about their bodies. What appears to be a purely personal issue in enhancement ethics may not be. Indeed, the range of the merely personal is itself an ethical issue in this debate.
The ethics of changing the human body has a pedigree. The ancient Greeks sought beauty in perfectly sculpted bodies to match the bodies of their gods. In the 1300s, Chinese bound the feet of little girls to make them tiny and lady-like.[1] Renaissance women strove for blondish-red hair, proportionately delicate bodies, and light-complexioned skin.[2] By stretching the necks of girls with bands of metal, some African and Asian cultures tried to create long, graceful necks.[3]
Philosophers Margaret Olivia Little and Susan Bordo believe that current female norms of appearance reflect social constructions and that cosmetic surgery unethically reinforces such norms.[4] They criticize the values of individuals who choose cosmetic surgery, the physicians who offer it, and the society that reinforces it.
Professor Little calls this serious objection “complicity with suspect norms.” She argues that the proper end of medicine should not be in helping women reshape their bodies to look like Barbie dolls. Others, such as physician-bioethicist Howard Brody and bioethicist Frank Miller, argue that physicians who offer such surgery violate the internal norms of medicine and its ideal of compassionate therapy.[5] They argue that cosmetic surgery is not what medicine should be for.
Social norms direct cosmetic surgery differently for distinct ethnic groups. For example, the most popular surgery among Asian women is double eyelid surgery, in which surgeons create a crease in the eyelid, whose effect is to make a bigger, rounder, more Western eye. Critics dislike how surgeons are altering Asian bodies to fit Western ideals. “You want to be part of the acceptable culture and the acceptable ethnicity, so you want to look more Westernized,” said Margaret M. Chin, a professor of sociology at Hunter College who specializes in Asian immigrant culture. “I feel sad that they feel like they have to do this.”[6] About 5 percent of Asians have some form of cosmetic surgery, about 750,000 in 2009 and about double the number in 2000 (versus 4 percent of Caucasians and 3 percent of Latinos).
One perspective on what Jennifer has done is that she is cheating. Why? She is pretending to be someone she is not. She is presenting herself to others, to men, in a body that is not her natural body. Isn’t that cheating those who interact with her? I’ll return to this issue later.
Another important issue about the ethics of enhancement concerns money. In bioethics, to understand an issue, always consider the money. You do not have to be a Marxist to appreciate the insight that how people make money influences their views. So if surgeons make money performing surgery, Marx would predict that—all other things being equal—surgeons would urge clients to have more surgery rather than less.
In the current scheme of medical reimbursement, something about money cries out about enhancement. Because insurance companies do not reimburse physicians for it, physicians doing this kind of medicine get paid directly by clients. Patient autonomy combines with consumer sovereignty to push medicine past its old boundaries.
Clients pay surgeons and dermatologists directly for weekly botox injections or for breast surgery. To do so, clients take out loans or make monthly payments over years on a schedule set up by the physician's office. This is far from the image of the compassionate country doctor accepting a chicken as payment from the poor patient.
These facts about money alter the moral landscape, and it is strange that so few discussions to date of the ethics of medical enhancement have analyzed how it does. It explains in part why so many people undergo too many cosmetic procedures too many times, too early, and in inappropriate circumstances.
One might argue that direct compensation doesn’t differ that much to the physician from compensation from insurance companies: either way, the more she operates, the more she makes. But that is not correct, for insurance companies have medical review by physicians and try not to pay for inappropriate surgery. But a rich woman may pay for several facelifts and be subject to only the review of her surgeon, who may praise the way she looks, even if she looks terrible.
An irony exists here, similar to one about assisted reproduction. For reasons connected to research on live-born fetuses, Congress in the mid-1970s banned federal funding of any experiment using human embryos or fetuses. Most insurance companies followed suit and did not pay for in vitro fertilization. When couples paid for such services with their own money, and clinics financed their own research from such payments, they realized that this financial cloud had an unexpected silver lining: they were not subject to review by the National Institutes of Health, local Institutional Review Boards, or committees at insurance companies doing medical review. In short, and much to the subsequent dismay of critics, they could do whatever kind of research they wanted.
Much the same thing has happened with cosmetic medicine. Although some techniques grew out of ordinary medicine—breast augmentation grew out of techniques for breast reconstruction after mastectomies—surgeons developed many techniques exclusively for enhancement and financed those developments from patients’ fees.
As such, most physicians who offer enhancement advertise for services as if they were selling cars. And like car salesmen, who are not out to sell you the best car for the least amount of money, so some physicians don’t sell clients the least amount of enhancement they need.
Worse, some patients don't know where to stop. If someone has been through weeks of swelling from cosmetic surgery on her face, and believes she looks much better, and has paid $10,000, it is difficult for the surgeon to tell her that she looks worse.
A related topic about the ethics of physicians in enhancement medicine concerns the outer boundaries of medicine. Now two types of physicians constantly push those boundaries: those in clinical research and those in assisted reproduction. It is inevitable that traditional physicians will find distasteful some procedures done by physicians in enhancement medicine, just as they find distasteful techniques of assisted reproduction. It is also true that malpractice is typically defined in state law as departing from the “customary and normal procedures of the medical community.”
Some critics worry that money paid for enhancement is diverted from other areas where it could be used better. But this is a specious argument: if I choose to buy an expensive car, forbidding me to do so does not entail that I will give the same money for relief of famine. Preventing physicians from entering enhancement medicine does not mean they will become physicians in primary care. It doesn't work that way, just as preventing women from enlarging their breasts doesn't mean the nonspent money will be diverted to better prenatal care for poor women.
What is true is that one part of medicine may distort the whole. If cash fuels one part of medicine, and the rest sags under paperwork and regulation, young, restless physicians will gravitate to the easier, flashier parts. And if huge distortions occur, national public policy must correct the imbalance.
So now we know that physical enhancement may serve dubious norms and those providing it may have conflicts of interest in giving impartial advice to clients about safety and risks. So what are the risks?
In North America and across the world during the last decades, surgical and pharmacological enhancement of the body has exploded. Between 2000 and 2007, 50,000 Norwegian women had breast implants.[7]
Such surgeries carry risk. Much cosmetic surgery is performed in outpatient, nonhospital settings. Florida has the best data on incidents in such settings because of its mandatory reporting law, having seven years of good data covering March 2000 to March 2007.[8] In these years, 31 patients died and 143 had serious complications, about 60 percent of which occurred after aesthetic surgeries. Liposuction under general anesthesia caused a significant number of these deaths.
Surgeons during the last decades performed vast numbers of cosmetic surgeries, and the most popular procedures were lipoplasty (liposuction), breast enlargement, breast reduction, rhinoplasty (nose jobs), eyelid surgery, facelifts, and botox injections.[9] Such surgery carries more risks than is commonly portrayed on television shows. Eight percent of French plastic surgeons have experienced a case of deep vein thrombosis and over half have had a patient with a pulmonary embolism.[10]
Consider bariatric surgery, considered by some to be a frivolous shortcut by obese people to normal weight. Such surgery can be a medical treatment of last resort when obesity threatens life. Morbid obesity causes diabetes, heart failure, breathing problems, bone breakage, passivity, and arthritis. A normal person’s Body Mass Index (BMI) varies between 18 and 25. A BMI of 25 to 30 classifies a person as medically obese; one over 30, as “morbidly obese.” The latter shortens lives dramatically.
According to the American Society of Bariatric Surgery Web site, bariatric surgery increased from 37,000 surgeries in 2000 to 177,000 surgeries in 2006.[11] Obviously, the same surgical techniques that extend lives of morbidly obese people also remove fat from arms, legs, stomach, and hips of less obese people, and thus, can enhance normality. But bariatric surgery carries significant risks and should not be considered as a quick, safe way to lose weight.
Liposuction is the most frequently performed cosmetic operation in Germany. Because of a liberal reimbursement system, between 1998 and 2003 German physicians did about 250,000 liposuctions, giving them good data from which to estimate risks.[12]
In those years of liposuctions, twenty-three patients died and about fifty others had extremely serious complications, such as necrotizing faciitis, gas gangrene, and sepsis. Almost as severe, other patients suffered pulmonary embolisms, hemorrhages, and perforation of internal abdominal organs. Lack of surgical experience and selection of unfit patients caused these problems, as well as unsterile techniques, which, in modern times, is unforgivable.
“Body contouring” with liposuction, even if safe, does not always achieve pleasing results. Physicians sometimes do not remove enough fat, leave palpable and visible irregularities, suck out too much fat, and the surgery itself generally creates hematomas, infections, swelling and bruising.[13]
Perhaps the most suspicious facial enhancement is botox injections. Botox is a neural toxin originating from Clostridium botulinum, which causes deadly botulism in meat. In moderate dosages, botox can be highly poisonous to humans. Some critics suggest that, over years, botox injections can leach into the brain.[14]
As therapy, botox can treat female urinary incontinence.[15] By paralyzing the muscles that urge women to urinate, researchers help such women gain more control over their bladders. Botox blocks neurotransmission in muscles, so as therapy, it’s also used to treat facial tics in adults or uncontrollable, muscular spasms in children.
For improving the youthful look of faces, doctors inject tiny amounts of botox to paralyze the facial muscles that create wrinkles. To maintain this effect, clients must see doctors every few months at a cost of $100-$200 per treatment. Botox creates a constant river of money for physicians who inject it because, to maintain the look, patients must get re-injected every few months as long as they live. (As one plastic surgeon says, “The amount of money you can make and the amount of time you spend [giving Botox] is unparalleled. You can make as much money Botoxing someone’s face in ten minutes as you can do in a two- or three-hour operation.”[16]
Facelifts are risky. Its most common complications (15 percent of cases) are hematomas, localized swelling filled with blood.[17] Facelifts in the twentieth century displayed overly tight skin or, when things really went wrong, a “Joker line” from a corner of a mouth to a cheek.[18] A prominent Manhattan plastic surgeon derides such antiquated results, claiming that the proper way to do this operation now is to leave patients with the flexible, bouncy skin of youngsters, not the tautly stretched, mummified look of old facelifts.[19]
Surgeons developed breast reconstruction with silicone gels to help women after mastectomies and later used these techniques to augment or decrease breasts for healthy women. In the 1950s and 1960s, surgeons used crude methods to augment breasts of 50,000 women, such as directly injecting silicone into them. In some cases, the tissue around the silicone became inflamed, hardened, and painful, so surgeons had to later perform mastectomies to remove everything. This is now considered a bad practice.
In the early 1960s, surgeons began implanting silicone-filled rubber bags, either between the chest wall and the pectoral muscles or between pectoral muscles and the breast. Dow Corning manufactured these bags. A decade later, surgeons used a less viscous silicone gel and a thinner sac, resulting in more ruptures. Claiming they had been harmed, women in the 1970s began class-action lawsuits against Dow Corning.
Because of these lawsuits, surgeons started to use saline-filled bags. However, even this procedure led to major complications including capsular contractures, when the rubber sac tightens and squeezes the saline, causing leakage from the capsule.
After three decades of silicone implants, over 400,000 women registered in 1995 as potential claimants in nearly 20,000 lawsuits against Dow Corning.[20] That May, because of costs of defending itself against these lawsuits, Dow Corning filed for Chapter 11 bankruptcy. In 1998, it filed for bankruptcy reorganization; to settle all claims against it, it agreed to compensate women for removal of breast implants or ruptures of silicone in them.
All the class-action suits in federal courts came to a head under the late federal judge Sam C. Pointer in Birmingham, AL., who in 1998 appointed four independent experts to review claims that the implants harmed women. These court-appointed masters concluded that medical evidence did not show that the implants caused any serious diseases. In 1999, the Institute of Medicine concluded the same, stating that although implants caused local scarring and hardening of surrounding tissues, they did not cause serious disease.[21] Several other large studies around the world came to the same conclusion.
At the end of 2011, about 70,000 women in France, Brazil, and Venezuela were told that they had received implants with an inferior, industrial-grade silicone rather than surgical silicone.[22] The latter is less likely to leak and, if it does, to cause irritation and inflammation. France offered to pay for its 30,000 women to undergo “explants.”[23]
Even if breast implants don’t cause disease, some women didn’t know enough before they got them. In one survey in 2007, 40 percent of women with implants believed that, before they had their surgeries, they should have learned more about their complications.[24] Perhaps they did not have the “serious disease” investigated by Judge Pointer and the Institute of Medicine, but thirty years later, some women reported neurological and rheumatological problems. In one study of a hundred women who had their implants removed, rheumatologists diagnosed autoimmune or rheumatic disease in eighteen of them. In this class of women, 75 percent had lost some sensitivity in their nipples, and twenty-five patients had lost all sensation.[25] These women had 186 implants removed, and of these, 57 percent had failed by rupturing or leaking, and bacteria infected 42 percent.
All implants eventually need to be replaced. Even with the best, third-generation implants, after ten years, 15 percent of women have implants replaced.[26] As one cosmetic surgeon says, “A lot of people have the wrong idea about augmentations. They don’t know that implants are not a lifetime device and that you’re going to have to have them replaced. If you have them at twenty, you’re probably going to have four or five revision surgeries over the course of your life.”[27]
Did most women who had implants years ago get informed consent about this? Did they know that women who smoke have twice the rate of complications as nonsmokers?[28] That for women getting experimental or premarket implants at discounted fees, after three years, the rate of reoperations runs as high as 20 percent?[29]
The proliferation of specialty boards confuses patients, even those who only want to use a “board-certified” physician. The American Society of Plastic Surgeons certifies almost all (90 percent) of America’s plastic surgeons. Another organization, the American Society for Aesthetic Plastic Surgery, also certifies plastic surgeons, but this society may have been formed in part by those who could not get, or refused to try to get, certified by the ASPS.
Contrary to what most people believe, any physician can do cosmetic surgery. A physician does not need to do a residency in cosmetic surgery to operate cosmetically. Dermatologists may operate cosmetically, and most who do belong to the American Society for Dermatologic Surgery. In some states, dentists can legally perform any surgery above the neck.
With the growing popularity of cosmetic surgery and lack of comparable incomes, practice shift has occurred in most states, where physicians uncertified in cosmetic procedures perform surgery to increase their incomes. Doing such surgeries outside a hospital is a loophole because more than half of states do not regulate cosmetic procedures outside hospitals.[30] Ideally, physicians who shift into other specialties should be held to the same standards of care as normal physicians in those specialties, which North Carolina recently has required.
Ultimately, the question of public policy comes down to whether physicians and customers should be banned from helping men and women reshape their bodies? Should society forbid people from paying physicians for aesthetic surgery, the way it forbids people from buying heroin or methamphetamine? Even Professor Little doesn’t go that far, and instead urges both patients and physicians to “fight against” the tyranny of the norm.
While it may be foolish to pursue such values, it’s hard to argue that it’s immoral. Yes, we criticize parents who spend every evening watching their kids play sports (they have no other interests?), but it’s not immoral to live that way. Some middle-aged singles live in St. Bart’s, sailing and drinking, soaking up the sun, and just hanging out. It may be a suspect norm to live like this and not much of a life project, but that isn’t immoral.
Moreover, most female clients of cosmetic surgeons do not view themselves as robots. They do not see themselves as being led by the nose of oppressive norms, but claim they deliberately chose a plan for social and professional advancement.
In addition to bodily enhancement for social and professional purposes, many people use medicine to restore their bodies after loss of function. They need such surgery after accidents from jobs, farms, and automobiles, and after falls and gunshot wounds. In addition, many people want to enhance their bodies not out of narcissism or in competition, but simply to be able to maintain their ability to work, to live independently, or to do favorite activities such as running, skiing, or bowling (hip replacements).
So suppose a woman reads all the above risks of cosmetic surgery and still wants to go ahead with, say, liposuction. Is she a fool to do so? Wasting public monies?
I believe that the range of human desires is so vast, so complex, and so individualized, that as a matter of law and morality, almost all personal enhancements should be allowed among competent adults.
So isn’t Jennifer cheating nature, creating a false impression of herself to potential suitors, and making other women feel inferior? I think the question assumes that no one knows what Jennifer has done, whereas in most cases, it’s obvious, especially when the person repeatedly pursues enhancements. The question also assumes that Jennifer isn’t open about what she’s done, and according to cosmetic surgeons, some women like Jennifer are not secretive about their enhancements.
Even if it wasn’t obvious and Jennifer kept it secret, I don’t see any great harm to others from what she’s done. It’s like parents hiring a private tutor so Johnny can do better on his SATs or become a better goalie in soccer. Yes, people do these things do get an advantage over others in competitions, but only the most dictatorial, intrusive state or puritanical ethics would get government involved in banning such private actions.
I agree with John Stuart Mill when he concluded in On Liberty that when the state forbids personal endeavors in such areas, it is very likely to do so for the wrong reasons at the wrong time and for the wrong motives. And even if justified in banning a particular case, the general principle is more important, which is that competent people should be left free to do what they want in their own lives, and modifying their bodies is about as personal as “their own lives” can get.
Nevertheless, something deeply troubles me about the secretiveness of the business of physical enhancement. I sense that thousands of women have undergone cosmetic surgery of one form or the other and that many may be unhappy. Nor do I believe that public monies should subsidize such enhancements, as in Europe, either by government programs such as Medicaid and Medicare or by group insurance.
It is difficult to find objective evidence of how happy or unhappy are the clients of cosmetic surgeons. It is not in the interest of the doctors cutting or prescribing to fund objective follow-up studies, so how do we know whether a huge percentage aren’t secretly sorry they did what they did? Perhaps patients are embarrassed to admit that they tried to become more beautiful and now suffer in private or admit that they did not anticipate the number of repeated visits to the doctor’s office needed to maintain their look.
If we had a national center to monitor such private enhancements, we could fund follow-up studies. We could require that a national registry be created so such studies could be done, the way we do to follow-up studies on premature babies.
Even without such a federal center, other entities could do the same. Why don’t we? Consumers Union sends me a survey every year to survey how I like what I bought in cars, washing machines, and phone coverage, so why can’t it survey elective surgery? Someone should be doing so.
I conclude that right now, we think about cosmetic surgery on females in an epistemic black hole. Recognizing that such enhancements are a huge business, and not knowing the long-term risks, we cannot easily evaluate them. This is an even greater problem with stealth enhancements in competitive athletics such as cycling and football, as we shall see next.
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Jayne O’Donnell, “States Take Aim at ‘Practice Drift’,” USA Today, December 28, 2011, B1–2.