Elective Cosmetic Surgery Body Image and Ethics

Abstract

The demand for and acceptance of cosmetic surgery has been steadily increasing over the past few decades. The ability to electively change one's appearance through surgery has always been a controversial idea. Proponents of cosmetic surgery argue that altering one's appearance to change a flawed feature will have a positive effect on one's self-perception and, therefore, improve overall wellbeing. However, others contend that surgical interventions do not promote lifestyle changes and do not have long-term effects on one's self-perception. Additionally, this debate over the effects of cosmetic surgery has provoked a discussion regarding the ethics of cosmetic surgery.  This paper offers a review of the current literature concerning cosmetic surgery and its effects on women's body image in an attempt to draw conclusions about the personal and social implications of cosmetic surgery followed by a review of bioethics and a discussion of the ethical implications of elective cosmetic surgery.

Cosmetic Surgery Over Time and Today

As reported by the American Society of Plastic Surgeons, in 2017 there were 17.5 million surgical and minimally invasive cosmetic procedures performed in the US, a nearly 200% increase since 2000 (ASPS, 2018). In 2017 in the United States 92% of people who underwent cosmetic procedures were women (ASPS, 2018). This is consistent with the idea that women are under a greater societal pressure to attain ideals of beauty and thinness. Given that the vast majority of patients who undergo elective cosmetic procedures are women, this paper will focus on the female perspective in an attempt to explain the stark increase in cosmetic procedures performed in the past few decades.

It was estimated by the American Society of Plastic Surgeons that Americans spent more than $16 billion on cosmetic surgeries in 2016 (ASPS, 2018).  Of the 1.8 million cosmetic surgical procedures performed in the United States in 2017, the most common were: breast augmentation, liposuction, nose reshaping, eyelid surgery, and tummy tuck (ASPS, 2018). Of the 15.7 million cosmetic minimally invasive procedures performed, the top five were: botulinum toxin type A, soft tissue fillers, chemical peel, laser hair removal, and microdermabrasion (ASPS, 2018). These procedures allow women to move closer towards the current American societal standard of beauty. This ideal is a thin woman with a small waist, large breasts, and soft feminine facial features.

Possible Causes for this Sudden Increase in Elective Cosmetic Surgery

There are multiple theories as to why there has been such an increase in cosmetic surgery throughout the past few decades. Recent medical advances have made subtle, minimally invasive procedures possible and developments in the medical field have made these procedures much safer and more accurate.

The increased internalization of sociocultural beauty ideas due to an increased exposure to media may be linked to this amplified drive to achieve and maintain a certain physical appearance. Cosmetic surgery has become more popularized -- reality television series transform the appearance of ordinary people, celebrities often speak of the cosmetic procedures they have undergone, or magazines expose those who have been under the knife. For example, television shows such as Keeping Up with the Kardashians or Extreme Makeover normalize the idea of undergoing cosmetic procedures by portraying them as typical and casual. These television series instill in the audience the need to pursue unrealistic beauty standards propagated by the general media today.

Moreover, the increased use of social media has also been linked to a greater drive for cosmetic enhancement. According to the American Academy of Facial Plastic and Reconstructive Surgery, 42% of facial plastic surgeons have seen patients who request surgery in an attempt to improve their image on social media (10). Additionally, in 2017, 55% of surgeons saw patients whose main motivation for undergoing surgery was to look better in selfies (11).

This increase in awareness of cosmetic procedures has led to greater public acceptance.  According to an online survey conducted by Harris Interactive, about 69% of adults say they would choose to under elective cosmetic surgery if not for financial restraints (ASPS, 2010). Additionally, marketing materials which promote lunchtime procedures promote a carefree outlook in regard to these elective procedures.  Furthermore, the nature of cosmetic surgery has shifted from reconstruction to self-improvement. Elliot proposes that there have been two major movements in modern American healthcare: a greater focus on improving the quality of life of healthy individuals and a major shift in the perception of healthcare from a basic human right to a market commodity (Elliot, 2005). According to Elliot, the ability to alter physical appearance through cosmetic procedures has morphed into another facet by which individuals measure their success through purchasing power (Elliot, 2005).

Who Undergoes Elective Cosmetic Surgery and Why?

Women choose to undergo cosmetic surgery for a variety of reasons; however, there are psychosocial and other factors which make certain women more likely to seek out these procedures. A 2006 survey of Norwegian women (22 to 55 years old) investigated which psychological variables are involved in possible relationship between body image and cosmetic surgery (von Soest, Kvalem, Skolleborg, & Roald, n.d., p. 52). Specifically, the researchers studied how self-esteem, teasing history, social acceptance of cosmetic surgery, and self-monitoring relate to a woman's motivation to undergo cosmetic surgery (von Soest, Kvalem, Skolleborg, & Roald, n.d.). Results and analysis indicate that all factors, except for self-esteem, were correlated with willingness and desire to undergo surgery (von Soest et al., n.d., p. 56).   Body image and acceptance of cosmetic surgery in an individual's environment were shown to be the strongest predictors of cosmetic surgery motivation (von Soest et al., n.d., p. 60). That is, those with lower body image and more acceptance of the idea of cosmetic surgery are more likely to wish to undergo surgery (von Soest et al., n.d.).

Additionally, a survey study conducted in 2016 in Iran explored the differences in body image dissatisfaction and psychological symptoms among groups of women who had undergone invasive aesthetic surgery, minimally invasive surgery, and a control group who had not undergone any elective cosmetic procedures (Yazdandoost, Hayatbini, Farid, Gharaee & Latifi, 2016, p. 148). The findings of this study indicate that body image dissatisfaction was highest in the invasive aesthetic surgery group and lowest in the control group (Yazdandoost, 2016, p. 151). Moreover, the invasive aesthetic surgery group displayed more appearance dissatisfaction and higher interaction of appearance and social function than the other two groups (Yazdandoost, 2016). This conclusion is consistent with previous findings and is particularly interesting in that it may relate to the idea that some people diagnosed with the most severe type of body image disturbance would cope with these problems by seeking elective aesthetic surgery (Yazdandoost, 2016, p. 151).

Generally, body image dissatisfaction is believed to be a primary motivation for cosmetic surgery (Cash & Smolak, 2012, p. 396). A variety of studies have concluded that cosmetic surgery patients tend to report higher body image dissatisfaction, compared to control groups (Cash & Smolak, 2012, p. 396). Interestingly, however, many patients report targeted dissatisfaction with the feature they chose to be cosmetically altered rather than overall appearance dissatisfaction. Furthermore, it has been shown that a subset (about 5-15%) of patients who undergo cosmetic surgery suffer from body dysmorphic disorder (Cash & Smolak, 2012, p. 396). These individuals often undergo cosmetic surgery to improve what they believe to be flaws in their appearance in an attempt to increase their self-esteem or body image satisfaction. Unfortunately, however, these efforts are often in vain as most patients with body dysmorphic disorder report either no change or worsening of their symptoms post operatively (Cash & Smolak, 2012, p. 396). Some patients manifest this disappointment by threatening to sue or physically harm the treatment providers (Cash & Smolak, 2012, p. 396).  This is just one example of why medical professionals must take proper precautions pre-operatively to ensure the mental health and realistic expectations of the patient.

Regrettably, many medical professionals continue to operate on those with body dysmorphic disorder or critically low body image satisfaction as these patients may also prove to be the most lucrative for the provider's practice. The overwhelming desire of these patients to reach an aesthetic ideal propagated by the media may inspire them to continue undergoing elective cosmetic procedures in a futile attempt to reach an unattainable standard of beauty. For this reason, it is imperative that medical professionals uphold an ethical medical standard by which they may lose immediate income; however, they must consider the patient's wellbeing above all else and if a patient is not psychologically fit enough to undergo an elective cosmetic procedure, providers must be willing and able to deny that treatment to that individual and recommend possible psychological rather than physical interventions.

Bioethics of Elective Surgery

As the demand for aesthetic surgery rises, abuses of ethical principles in surgery are also increasingly notable. In 1979 the Principles of Biomedical Ethics was published and presented four basic principles that have since been adopted as the ethical basis for contemporary medical practice (Mousavi, 2010). The principles were defined as: respect for autonomy, beneficence, non-maleficence and justice (Mousavi, 2010). Originally, these pillars were used to guide medical professionals in treating individuals suffering from illnesses. As modern culture continues to strive towards an ageless beauty ideal and the cosmetic procedures performed increase annually, it is imperative to reanalyze these concepts through a modern lens.

Respect for Patient Autonomy

Adult patients have the right to choose whether to undergo a procedure, and the patient's wishes should be respected, given they have all the relevant information (Mousavi 2010). This principle is particularly important in the case of elective aesthetic surgery because the patient is not suffering from any actively harming illness and the operation, itself, may have negative long-term effects on the body (Mousavi 2010). That is, the patient is choosing to endure the risk of surgery to fix a perceived problem with which one could very well continue to live. This principle may present a dichotomy with the non- maleficence principle (discussed below), and in such cases, medical practitioners should respect the patient's decision while ensuring that the patient's expectations are realistic and that the patient is aware of all risks involved with the procedure (Mousavi 2010).

Beneficence

This principle encompasses the general idea that medical providers must act in the best interest of the patient; however, defining a patient's best interest may prove complicated (Mousavi 2010). Given the case of aesthetic surgery, it is possible that the operation would improve the patient's body image and overall outlook, making the patient more content and socially confident (Mousavi 2010). Contrastingly, as mentioned above, patients who present with body dysmorphic disorder would not benefit psychologically from major elective cosmetic interventions as these patients will likely never be satisfied with their appearance (Mousavi 2010). As mentioned above, patients who present with this psychiatric syndrome may benefit more from psychiatric treatment than from physically altering their appearance.

Non-Maleficence

The non-maleficence principle states that a medical provider should never act against the best interest of the patient or in a way that may cause harm to the patient (Mousavi 2010). That is, professionals should decline to treat patients if they have reason to believe that the patient would not benefit from this elective procedure (Mousavi 2010). To continue with the above example, a provider should choose not to perform any major aesthetic operations or procedures on a patient with body dysmorphic disorder as this would not be in the patient's best interest. Additionally, surgeons should be cautious when operating on patients with unrealistic expectations as to the results of the surgery as the risk of surgery may outweigh the benefits. It is important to note that these judgements are made on an individual, case-by-case basis. This principle also prohibits medical professionals from performing a procedure simply for their personal monetary gain (Mousavi 2010). All surgeons should hold their duty to care for patients as the first and foremost principle of their practice.

Justice

The justice principle requires doctors and medical professionals to ensure that medical care is accessible to all (Mousavi 2010). Though this principle is difficult to apply perfectly in practice, it is necessary to acknowledge that access to healthcare is regarded as a basic human right. It is worth noting that in the private sector, those who can afford the treatment are treated while those who cannot must look elsewhere (Mousavi 2010).

Social Considerations

Though this is not a principle of bioethics, it is interesting and valuable to consider the social implications of this growing field of medicine. Given the increased focus on body image in this modern consumer society in which people are constantly inundated with images and ideas from the media regarding how one should look, it is important to reflect on the possible effects of an increasing plastic or aesthetically fixed population (Mousavi 2010). As mentioned above, the people who undergo cosmetic surgery are disproportionately of a higher socioeconomic status, simply because this is the cohort which can afford to undergo these elective procedures (Mousavi 2010). This prompts the question of whether these procedures are creating a physical divide in the population today between the average person and one who has had the ability to choose to reconstruct their body and aesthetic features in an attempt to attain the ideal beauty standard of today (Mousavi 2010).

Further questions to regarding bioethics

Though there are no definitive answers to these questions, it is a valuable exercise to consider these implications when thinking about elective cosmetic surgery. Due to limitations in space and my expertise, only some of the questions posed below will be briefly discussed:

1. How should professional societies regulate the evolving field of genetic aesthetic enhancement? What, if any, differences exist between eugenics and genetic aesthetic enhancement? (Donohoe, 2006)
2. What roles do culture and the media play in individual and public perceptions of beauty and the desire for cosmetic surgery?
3. Should the media's role in promoting cosmetic surgery be mitigated in any way?

Given that increased exposure to media is linked to heightened body dissatisfaction, it is in the best interest of parents and caregivers to monitor their children's use of social media in an attempt to safeguard their children from these negative effects.

4. Are medical professionals obligated to provide psychological recommendations to patients?

In my opinion, I believe medical professionals are obligated to provide psychological recommendations to patients in concordance with the beneficence and non-maleficence principles described above. If it is in the best interest of the patient to meet with a psychological counselor, then it is the duty of the medical professional to act in the patient's best interest and suggest this to them.

5. Is aging defined as a physical and/or mental illness? If so, is the substitution of happiness for health an appropriate goal for cosmetic enhancement? Does this enhancement constitute medical treatment? Or is cosmetic surgery simply a business service provided to those who desire it, can pay for it, and are willing to accept the risks involved? (Donohoe, 2006)
6. What are the appropriate actions of health professionals, lawyers, teachers, ethicists and governments in responding to ideals of beauty and body weight, and to unhealthy behaviors and unsafe and/or unethical cosmetic surgical practices? (Donohoe, 2006)

References

1. American Society of Plastic Surgeons (ASPS). (2018, March 01). New Statistics Reveal the Shape of Plastic Surgery. American Society of Plastic Surgeons. Retrieved from https://www.plasticsurgery.org/news/press-releases/new-statistics-reveal-the-shape-of-plastic-surgery.
2. von Soest, T., Kvalem, I., Skolleborg, K., & Roald, H. (n.d.). Psychosocial factors predicting the motivation to undergo cosmetic surgery. Plastic and Reconstructive Surgery: Journal of the American Society of Plastic Surgeons., 117(1), 51“62. Retrieved from https://proxy.library.upenn.edu:2092/sp-3.31.1b/ovidweb.cgi?WebLinkFrameset=1&S=AJBOFPNLFODDEDIDNCEKPDGCANLIAA00&returnUrl=ovidweb.cgi%3f%26Full%2bText%3dL%257cS.sh.41.42%257c0%257c00006534-200601000-00009%26S%3dAJBOFPNLFODDEDIDNCEKPDGCANLIAA00&directlink=https%3a%2f%2fovidsp.tx.ovid.com%2fovftpdfs%2fFPDDNCGCPDIDFO00%2ffs047%2fovft%2flive%2fgv024%2f00006534%2f00006534-200601000-00009.pdf&filename=Psychosocial+Factors+Predicting+the+Motivation+to+Undergo+Cosmetic+Surgery.&pdf_key=FPDDNCGCPDIDFO00&pdf_index=/fs047/ovft/live/gv024/00006534/00006534-200601000-00009
3. Elliott, C. (2005). Medicine Goes to the Mall: Enhancement Technologies and Quality of Life. Virtual Mentor, 7(2). doi: 10.1001/virtualmentor.2005.7.2.msoc1-0502. Retrieved from https://www.ama-assn.org/ama/pub/category/14570.html
4. Yazdandoost, R. Y., Hayatbini, N., Farid, A. A. A., Gharaee, B., & Latifi, N. A. (2016). The Body Image Dissatisfaction and Psychological Symptoms among Invasive and Minimally Invasive Aesthetic Surgery Patients. World journal of plastic surgery, 5(2), 148-153. Retrieved from https://proxy.library.upenn.edu:2065/pmc/articles/PMC5003950/pdf/wjps-5-148.pdf
5. Cash, T. and Smolak, L. (2012). Body image. New York, N.Y.: Guilford Press.
6. Mousavi S. R. (2010). The Ethics of Aesthetic Surgery. Journal of cutaneous and aesthetic surgery, 3(1), [online]. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2890136/
7. Donohoe, M. (2006). Women's Health in Context: Cosmetic Surgery Past, Present, and Future: Scope, Ethics, and Policy. Medscape Ob/Gyn., 11(2), [online]. Retrieved from https://www.medscape.com/viewarticle/542448_print>
8. American Society of Plastic Surgeons (ASPS). (2010). New Survey Shows Interest in Cosmetic Surgery is Up - Body Contouring and Antiaging Procedures Top the List American Society of Plastic Surgeons. Retrieved from https://www.plasticsurgery.org/news/press-releases/new-survey-shows-interest-in-cosmetic-surgery-is-up
9. https://www.aafprs.org/media/press-release/20170616.html
10. https://www.aafprs.org/media/stats_polls/m_stats.html

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