Eyes Wide Open: Surgery to Westernize the Eyes of an Asian Child

Alicia Ouellette

The Hastings Center Report. 2009;39(1):15-18. 

In This Article

In the Eye of the Beholder: What Is at Stake?

It is hard to say that the father was not acting in his child's best interest, as he defined it, when he opted for surgery. Nonetheless, the case is troubling. Not only was his child exposed to the actual harm of surgery for purely cosmetic reasons, but she may have been damaged in less tangible but no less important ways.

The literature describes blepharoplasty on the Asian eye as a straightforward and fairly simple procedure. After the patient is sedated and anesthetized, the surgeon makes an incision above the eyelid and removes skin, tissue under the skin, and fat pads. The surgeon then sutures the incision and packs the eye with a light dressing. Once the wound heals, the incision disappears in the newly formed crease. In addition to the usual risks of surgery, eye-shaping surgery poses the risk of hematoma, asymmetry, and drooping. Recovery may be uncomfortable.

Although some women see the surgery as a rite of passage, it is controversial even for adults.Christina Valhouli quoted a twenty-nine-year-old Korean American as saying that she "had the eyelid surgery done her junior year of high school, largely because of nudging from her mother, who had it done as a child in Korea." A young woman on The Oprah Winfrey Show explained that eye-shaping surgery "wasn't a vanity thing. It really was this belief that if you looked a little more Western and a little less Asian, it's like having a great degree from a better school. . . . It was something to put in your portfolio." Others condemn the surgery as an attack on ethnic identity. Another woman quoted by Valhouli describes the surgery as "trying to get rid of something that is so distinctly ethnic." Eugenia Kaw argues that "The desire to create more 'open' eyes or 'sharpen' noses is a product of racial ideologies that associate Asian features with negative behavioral or intellectual characteristics like dullness, passivity, or lack of emotion (the proverbial Oriental bookworm)."[9] Surgeons have become increasingly conscious of the criticism of the surgery and have developed techniques to duplicate naturally occurring Asian double-eyelids, theoretically allowing them to open the eyes without "Westernizing" them.[10]

Despite the controversy, hundreds of thousands of Asian American adults have elected to have eye-shaping surgery for the same reasons the surgeon-father chose it for his daughter. If the father was the decision-maker for the child—the person best situated to decide what is in his child's best interest—and he determined that surgery was in her best interest, then his election of surgery for his daughter was quite appropriate.

The problem with this reasoning, of course, is that the child is, well, a child. She is an individual with full personhood rights, but an incomplete capacity to exercise all those rights. Unlike an adult who chooses to expose herself to the physical risks of surgery, she exercised no choice and was unable to reach and express her own view on the value of the controversial surgery. Her father made choices and imposed them on her.

The same can be said about all medical choices made by parents for children, but two things separate this case from the run-of-the-mill medical case. First, no medical, psychological, or physical impairment triggered the need for a parental decision; the father chose the surgery based on his aesthetic preference. Second, the intervention itself permanently altered a feature that is to some people an integral aspect of identity. These points make a moral difference. Most parental decisions to treat a child medically or surgically are a response to a physical or psychological impairment, illness, or injury in the child. In those cases, some need of the child triggers the decision to intervene, and the parent is the best person to sort through the medically appropriate choices for the child. But when a parent modifies features of a child that have nothing to do with physical impairment but can be integral to identity, and bases that decision on his own needs or aesthetic preferences, he asserts physical control over the child's body in the same way that he might assert control over a piece of property that he can modify to his specifications.

The point can also be put in terms of the child's autonomy. A child has autonomy interests even if she currently lacks the power or capacity to exercise them. While a parent must sometimes act as the child's agent to exercise those autonomy interests, this power is not unbounded. The parent holds the child's right to autonomy in trust.[11] As trustee, the parent must sometimes make choices for the child, but he must also preserve certain choices for the adult the child will become. For example, he cannot choose whom his child will marry, as this choice rightly belongs to her alone when she is grown. The same principle applies to medical decisions. The parent has a duty to preserve for the child the right to make her own decisions about controversial, unnecessary surgery until that child is an adult unless some medical or other necessity triggers the need for an immediate decision. When needs arise, meeting them through an immediate parental decision is more important than preserving the child's ability to make her own decisions in the future. But when intervention is sought to "improve" a child through surgery or medicine for cultural or aesthetic reasons, the impairment to the child's autonomy is hard to justify.

The nature of the surgery makes the case especially troubling. For some people, the shape of the eye is an integral part of ethnicity, a component of identity. A change to it may, therefore, go deeper than the removal of a mole or the pinning of a child's ears. In choosing the surgery, the father took from his daughter the ability to make her own choice about her identity. His exercise of parental autonomy thus limited his daughter's potential autonomy in a critical way; it took away her right to make a decision central to her identity as an adult, a right that is, like others, central to an open future.[12]

In this way, the case is similar to those involving surgical "correction" of ambiguous genitalia, and even female genital cutting. Scholarship about the long-term effects of genital assignment surgery makes a strong case that surgically assigning a gender to a child born with ambiguous genitals may have horrific consequences as the child matures.[13] And female genital cutting—a culture-bound, medically unnecessary ritual—is so harmful to a child's future sexuality that it is banned in all cases, even in those in which physical trauma is minimal.[14] Gender and sexuality are integral components of identity. So, too, is ethnicity. Just as genital surgery and female genital cutting may cause long-term psychological trauma through an insult to identity, so the permanent modification of a child's eye may cause trauma through its insult on identity. At the very least, the long-term consequences of eye-shaping surgery on children are unknown.

The fact that the father was a new adoptive parent makes his decision feel particularly egregious. Perhaps because adoption already involves an exchange, worries about ownership seem closer to the surface. As a result, the adoptive parent seems to have a stronger obligation to accept the child's individuality, especially if the adoption is cross-cultural or cross-racial. But this is a matter of appearances. All parents have the same obligation to accept the child as an individual with separate interests from the parent.