Indian Journal of Medical Ethics Vol IV No 4 October- December 2007
[ 171 ]
Concerns about cosmetic surgery
AVINASH DE SOUSA
Consultant psychiatrist. Carmel 18 St Francis Avenue, Willingdon colony, Santacruz West, Mumbai 400 054 INDIA
This article looks at some ethical challenges in cosmetic surgery.
Enhancement versus therapy, risks, patient autonomy, beneﬁcence
and informed consent are issues that need to be considered when
considering cosmetic surgery in today’s world.
Altering human physical appearance is as old as recorded
history. Evolutionary biologists have linked our desire for
altering the body to innate biological drives for partner
selection and reproduction. We currently stand at a unique
point in the history of such practices. Our unprecedented
ability to alter human appearance raises new questions
about the nature of non-therapeutic, cosmetic surgery, and
the justiﬁcation for altering the body for purposes other than
to cure diseases. Science and technology offer us genetic
engineering and gene therapy, prosthetic limbs and brain
computer interfaces that change what we mean by human
People have often questioned the justiﬁcation for undergoing
surgery to alter appearance rather than to cure inﬁrmity. Many
studies have failed to demonstrate the safety and long-term
efﬁcacy of certain cosmetic surgery procedures. There are
additional risks in surgeries of long duration and in multiple
surgeries. There is little work in this ﬁeld on issues such as
surgical experimentation and innovation; nor has it drawn up
accepted guidelines of practice (2). Such issues are important
because implicit in the practice of cosmetic surgery is the
notion that physical beauty as deﬁned by certain social norms
is not only a goal to strive for, but also a goal for which one
might undergo a potentially risky procedure. There is also the
question of whether cosmetic surgery should resist or cater to
a patient’s desires (3).
Enhancement versus therapy
Ethical arguments in support of cosmetic surgery have focused
on the notion of altering the human form for beneﬁts that lie
on the hazy boundary between enhancement and therapy (4).
Others view the pursuit of aesthetic improvement as either a
personal vanity or a lamentable submission to the superﬁcial
priority placed on appearance in a corrupted society (5).
Major questions arise from these tensions. Should cosmetic
surgery be a matter of consumer desire alone, that does not
need medical justiﬁcation? Is it then removed from the realm of
medicine as we commonly understand it? As it becomes more
widely used one must ask: what are appropriate or “correct”
applications for such surgery? When is it inappropriate?
Should cosmetic surgery be used to help people conform to
media messages of what is considered beautiful? Given that
beauty is deﬁned by the culture dominant within a society,
should cosmetic surgery be used to change ethnic traits?
Does cosmetic surgery violate some notion of justice when
it is available only to those who are wealthy? Should there
be guidelines for the use of cosmetic surgery on children
and teenagers? Should there be an age for consent to such
procedures? While there are no deﬁnitive answers to these
questions they are of critical importance today with the
increase in cosmetic surgery in ethnic alteration, and with the
emergence of new possibilities. It is thus essential to deﬁne the
legitimate and illegitimate uses of cosmetic surgery (6).
Beneﬁcence and nonmaleﬁcence
Beneﬁcence means an ethical duty to maximise beneﬁt. Non-
maleﬁcence refers to the duty to reduce risk. Physicians have a
duty not only to avoid harm to the patient but also to weigh
the risks of the surgery with the needs of the patient and to
offer a plan that will provide him or her maximum beneﬁt. If
patient beneﬁt is not the ultimate outcome then the principle
of beneﬁcence is violated. Taking this argument forward, one
must ask whether catering to the patient’s desire for cosmetic
change is in the patient’s best interests. It is challenging to
apply this principle with respect to cosmetic surgery. Measuring
beneﬁts like long-term outcomes and quality of life is difﬁcult
and few studies on the long-term positive effects of cosmetic
surgery exist (7).
Risk is the probability of negative consequences of a desired
action. All surgery involves risk and this risk must be fairly well
deﬁned before surgery is undertaken. While cosmetic surgery
may involve relatively modest risks, they do exist. Professional
groups must work to ensure, to the extent possible, that
such surgeries are held to the highest medical standards and
complications minimised. The profession is also responsible
for ensuring that the public is always informed of all the
risks involved. The lack of self-regulation and the increase in
ambulatory clinics have increased the risks faced by people
undergoing cosmetic surgery. There is a need to maintain
professional standards and regulate the practice of cosmetic
Indian Journal of Medical Ethics Vol IV No 4 October-December 2007
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The principle of autonomy is based on the idea that we have
the capacity to make choices. We have the right to determine
what will happen to our own bodies. Patient autonomy is made
up of negative and positive freedoms. The negative freedom is
freedom from coercion by others; positive freedoms are those
that allow self- determination, self-expression and choice. The
patient must not only have the ability to say “No” but must also
be sovereign in his or her decision-making capacity. All cultures
and races have their concept of beauty. The need to conform
to that norm may put so much pressure on a person that he
or she feels compelled to undergo cosmetic surgery. In some
ways, the media and social pressures work together to force the
decision to undergo cosmetic surgery. The principle of choice
may apply to all aspects of healthcare. A fundamental question
is whether cosmetic surgery constitutes healthcare. Some have
viewed the practice of cosmetic surgery as outside traditional
Informed consent must be obtained from the patient before
any medical intervention. There is an important distinction
between ethically obtained informed consent and legally
effective consent. Ethical consent denotes a decision-making
process based on mutual respect and full disclosure; it
describes an interaction between doctor and patient over time,
one that is more than just getting a signature on a consent
form. The patient must be informed about the procedure by the
surgeon himself. Patients must be given enough time to assess
risks, make decisions and ask all the questions they wish to ask.
They should never be pressured to make a decision before they
Well informed patients will have fewer anxieties during surgery
and better compliance with instructions. They cope better with
complications and express greater satisfaction with the results
The success of informed consent is largely based on effective
communication between doctor and patient and the ability
of the patient to understand what is being communicated.
This process can often fail because of the doctor’s poor
communication skills or because of the patient’s preconceived
notions and expectations (10).
Surgeons also have the responsibility to rule out major
psychiatric disorders in their patients. At the very least, they
must refer patients to a mental health professional prior to
surgery. It is possible that some psychiatric patients have
a diminished autonomy and decision-making capacity.
Surgeons therefore have an ethical responsibility to make that
determination before conducting surgery.
The inﬂux of managed care in the US has encouraged medical
professionals in various specialities to treat medicine as a
business. Cosmetic surgery, too, is treated as a commodity.
India is no exception to this trend. False and misleading
advertisements ﬂourish in the media and on the internet in
the ﬁght for a share of the market, and the patient’s welfare
becomes second priority as gimmicks are promoted in the
name of scientiﬁc development. This also raises questions
about the nature of voluntariness and full disclosure (11). Even
if one believes that cosmetic surgery can help in the promotion
and maintenance of health, such commercialisation is contrary
to efforts to make the discipline a legitimate medical practice
As in any medical and surgical specialty, cosmetic surgical
procedures should be subjected to rigorous research protocols
before they are used on patients. Any clinical research initiative
in cosmetic surgery must adhere to the highest standards
of research subject protection. The line between surgical
innovation and human experimentation is a murky one. The
emphasis must always be on safeguarding the health and
welfare of the patients involved.
There is very little regulation of the use of speciﬁc products for
cosmetic surgery purposes. There is relatively little monitoring
of the efﬁcacy and safety of cosmetic surgery procedures and
treatments and only limited mechanisms to prevent the use of
demonstrably harmful procedures exist.
Cosmetic surgery has increased in the last decade. Not
only has its popularity soared but media coverage has also
increased. Media promotion of cosmetic surgery makes it more
acceptable for individuals to use it to improve their appearance.
Consequently, consumer pressure is responsible for the growth
of cosmetic surgery. Cosmetic surgery is the most prominent
example of a new focus on lifestyle medicine in which tools
that were earlier viewed as appropriate for therapeutic goals
are now ﬁnding application as consumer products. This also
leads us to consider our quest for perfection at an individual
and societal level. It also provides an avenue to consider the
limits of capitulation to consumer desires. Parents may request
cosmetic changes in the physical appearance of their children
with Down’s syndrome but this surgery does not mask the
cognitive deﬁcits that would persist in the child. We must make
sure that cosmetic surgery is used to enhance one’s self image
and well being and that it meets the intended goal while
minimising risks to the patient (13).
Deﬁnitions of normalcy
The goal of cosmetic as opposed to reconstructive surgery
is to improve the appearance of an individual who has an
abnormal appearance. Some argue that normalcy cannot
be operationally deﬁned and it depends on the individual’s
subjective perception. The judgments of normalcy lie on a
continuum and may be viewed differently not only by the
individual but also society. A cleft lip may be viewed by society
as abnormal in appearance and corrective cosmetic surgery
may be encouraged in such cases. A prominent nose may not
be considered abnormal by society but for the individual, it
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[ 173 ]
may be unacceptable enough to prompt him or her to undergo
surgery. Adolescents experience much emotional turmoil as
part of their psychosocial development. When teased about
physical qualities that do not conform to the norm, they may
experience sufﬁcient suffering to consider surgery as a solution.
Teenage breast augmentation is no longer a very unusual
procedure in some parts of the West. The clear ethical mandate
is that cosmetic surgery on adolescents should be discouraged
in general and taken up only if there is a compelling need and
after thoughtful consideration (14).
I have tried to examine the ethical issues in cosmetic surgery
in this article. The increases in demand of this type of surgery
and the advocacy of practice in the media have raised concerns
about the circumstances under which cosmetic surgery is
ethical and permissible. The steps needed to improve the
ethical practice of cosmetic surgery are very clear. Scientiﬁc
evidence of the safety and efﬁcacy of cosmetic procedures and
devices is needed to assure the public that the interventions
being offered have been evaluated properly for their efﬁcacy
and safety. Certiﬁcation of cosmetic surgeons and a closer
regulation of cosmetic surgery facilities will increase quality
and protect patients. The potential for the abuse of cosmetic
surgery must also be considered. It is a good example of the
need to balance beneﬁcence and autonomy. A patient desiring
cosmetic surgery should not be assured of getting it on the
strength of that desire alone. The surgeon should decline
such a request if it is felt that the patient will not beneﬁt
from the surgery or is not mature enough to understand the
ramiﬁcations of the procedure. Surgeons must be cognisant of
their actions when conducting a cosmetic surgical procedure
that may enforce a cultural norm. We must respect cosmetic
surgery but be wary of its overuse. The eternal questions are
whether cosmetic surgery can contribute to making us content
with ourselves and what it is that we aim to achieve by altering
ourselves and our bodies.
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