Women’s Health in Context: Cosmetic Surgery Past, Present, and Future: Scope, Ethics, and Policy

Martin Donohoe, MD, FACP


Medscape Ob/Gyn. 2006;11(2) 

In This Article

Ethical and Policy Issues Related to the Ideal of Beauty and Body Modification

The current pervasiveness of body modification and cosmetic surgery raises a number of provocative and controversial ethical and policy questions. Space precludes a full discussion of each, but such questions include:

  • What roles do culture, the media, sexism, and racism play in individual and public perceptions of beauty? Individual and collective perceptions of ideal body weight? The response of society to outliers and development of pathological behaviors? The desire for cosmetic surgery?

  • Is aging defined as a physical and/or mental illness?[42] 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?

  • How do providers and insurers define medical necessity as it relates to cosmetic surgery?

  • A sizable minority of physicians admits to "gaming the system" by manipulating reimbursement rules so their patients can receive treatments or undergo procedures the physician deems necessary.[43] How often do cosmetic surgeons "shade the truth" in attempting to obtain coverage for services they perceive to be necessary for their patients?

  • How much revenue-generating cosmetic surgery is too much for underfunded, university dermatology (or plastic surgery) departments?[44] What are appropriate arrangements for using such revenue to cross-subsidize indigent care?

  • To augment lagging revenues and offset budget deficits, states have begun taxing cosmetic procedures; New Jersey's levy is 6%.[45] Should cosmetic surgery be subjected to the same sort of consumption taxes as cigarettes and gasoline?

  • Many endocrinologists treat short-statured, non-growth hormone-deficient children with growth hormone.[46] Is it appropriate for parents to consent to such "treatment" and for physicians to offer it? Provision of growth hormone may augment height and enhance social acceptability (and ability to make the basketball team), but can carry potential long-term side effects such as diabetes and hypertension.[47]

  • Should surgeons correct the physiognomy of children with Trisomy 21, giving them a "normal" appearance while leaving their underlying neurologic defects and distorted voices unchanged? How will such surgery affect their emotional development and integration into society?

  • What cosmetic procedures are acceptable in consenting adolescents?[48]

  • Should cosmetic surgery be used to transform racial characteristics, by (as one author put it) "transforming a Black nose into an aquiline nose better befitting a British butler," or by rounding off the eyelids of Asians?[49]

  • How should professional societies regulate the evolving field of genetic aesthetic enhancement? What, if any, differences exist between eugenics and genetic aesthetic enhancement?

  • 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?

Body modification, ranging from the fairly innocuous ("tattoos") to the patriarchal and abusive (female genital cutting or female genital mutilation), has been common throughout history and remains widespread today. Some have argued that while ultimately it would be ideal for society to overcome its prejudicial attitudes regarding external appearance, it may at times be unreasonable to expect 1 individual to stand alone and not undergo cosmetic enhancement in order to alter public opinion. The typical example of this is a woman who, in her 40s or 50s, has developed age-related wrinkles, sagging eyelids, jowls, and a drooping bosom. She may (quite correctly) argue that it is more difficult for her to gain employment in professions where she will interact frequently with the public, or that she is less likely to be promoted.[2] Is it fair to ask this woman, whose income may support both her and her children, to forgo cosmetic reconstruction and attempt to overcome established prejudices in order to "show others" that she is able to succeed on the basis of her intrinsic worth?

Humanitarian Ventures in Plastic and Reconstructive Surgery

Many plastic, reconstructive, and cosmetic surgeons have applied their skills to laudable humanitarian endeavors. These include Operation Smile, where participating physicians correct congenital defects in poor patients in the developing world, and Face to Face: The National Domestic Violence Project (sponsored by the American Academy of Facial Plastic and Reconstructive Surgeons), which assists victims of partner abuse and sexual assault.[50] The Plastic Surgery Educational Foundation, the educational and research arm of the American Society of Plastic Surgeons, also helps to support plastic surgeons that volunteer abroad to help the impoverished.[51]


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