Ethical issues in cosmetic surgery
Professor Meningaud - Maxillofacial Surgery at Paris Est Créteil
Is surgery in general, and plastic surgery in particular, ethically different from medicine? The specificity of plastic and aesthetic surgery lies in its systematic work involving form, in the literal sense of the term. The stakes may be functional (covering a knee, mandibular reconstruction), almost always psychological (cosmetic surgery, disfigurement, victimology) or vital (necrotizing fasciitis).
But in all cases, the singularity of this surgical discipline lies in having to deal with a form that needs to be reconstructed or improved. This singularity has been at the root of major ethical debates in at least three areas: face transplantation, cosmetic surgery and sexual conversion surgery. In addition, this singularity necessarily sheds a different light on ethical questioning in the field of research and medical pedagogy.
Introduction
The four principles of bioethics are, in chronological order:
– the Mosaic principle of justice;
– the Hippocratic principle of non-maleficence (primum non nocere);
– the Christian principle of beneficence;
– the Kantian principle of the autonomy of the will.
Today, whatever the discipline, medical or surgical, the principle of respect for the law is still relevant. The Hippocratic principle is still part of the oath that every doctor takes just after defending his thesis. It remains a beacon for our difficult decisions. The principle of beneficence was still predominant when I was an intern and head of a clinic. Its paternalistic connotations wearied me for a while.
I have the impression that it is resurfacing as we realise that perfectly informed consent is a fiction that is certainly useful for making legal decisions, but remains a utopia on the scale of how the human brain works. Indeed, an answer begets a question, and some of us have spent more than 30 years wondering about a single pathology. It’s understandable that a patient can never be fully informed, given that every honest know-it-all considers himself to be an ignoramus. Despite this, the dominant principle today is that patients should be able to set their own standards (autonomy), i.e. to make decisions freely and responsibly, based on the most exhaustive information possible. Do these principles distinguish surgery in general, and plastic surgery in particular, from medicine [1]? I don’t think so. But as in ancient theatre, while the actors may remain the same, the masks change.
Ethical issues in cosmetic surgery
In 2002, when Dr Peter Butler, a plastic surgeon at London’s Royal Free Hospital, announced his intention to transplant a face, the facial specialist could not help but be perplexed by the media reaction he triggered. Part of the debate centred on whether it was ethical to take someone else’s identity (in the sense of likeness)! No one had bothered to find out whether this hypothesis, admittedly exciting in terms of formal reasoning, was valid on a scientific level and therefore, ultimately, whether it could be used to make a decision.
In fact, the face is not just an aesthetic interface, but also a set of tissues that enable essential functions such as phonation, swallowing, eye protection, breathing and, of course, numerous social functions. During the first ethical debates, the functional aspect of the face was completely erased in favour of discussions on its symbolic charge. As a face specialist, I can assure you that when a patient has no face, it’s the functional aspect that really comes to the fore. Above all, the patient wants to be able to perform all the functions mentioned above.
What are the ethical issues raised by face transplantation?
First of all, there are all the issues surrounding respect for the donor’s dignity. As far as the recipient is concerned, there are many questions.
Is it ethical to perform a face transplant on a patient who has attempted suicide, given the risk of recurrence? Is it ethical to perform a face transplant on a blind patient? What is the value of informed consent, given that the patients concerned are most often desperate? Should face transplantation be considered as research or care? What is the cost/benefit ratio of the operation, given that these procedures are extremely expensive and that the sum allocated would be used to treat many other patients with other pathologies (classic ethical discussion of individual versus collective benefit)? What about media coverage of these procedures?
In fact, the most important question is: is it ethical to offer a face transplant?
When the first transplant took place, in Amiens in 2005, the risks were known, but the benefits were obviously not, since no face transplant had ever been performed. The risks of immunosuppressive treatment were already known, thanks to experience gained from other organ and composite tissue transplants (hands). On the other hand, it was known that a certain number of disfigured patients required more than fifty surgical operations, with unsatisfactory benefits. In the end, it was experiments carried out in various countries, notably France, Spain and the United States, that provided a number of answers. We were able to observe that, contrary to what we had imagined, all transplanted patients required further operations to perfect their results. Patients also showed considerable functional improvement, but could not go completely unnoticed aesthetically.
Finally, the anticipated risks of acute or chronic rejection unfortunately materialised in practice. To sum up, specialists consider that face transplantation remains ethical, but only in exceptional cases, which must be evaluated by expert committees in facial reconstructive surgery, particularly in the field of disfigurement. Face transplantation is probably a milestone in the history of medicine. Many researchers, like Benoît Langelé, are working on decellularized and reseeded grafts. Others are working on bioprinting. New ethical issues will arise.
Cosmetic surgery
Cosmetic surgery poses a considerable ethical problem, that of the benefit/risk ratio of procedures with no functional benefit. When a patient has a leg fracture, intestinal obstruction or nasal cavity permeability disorder, the expected benefit of the operation is obvious. In cosmetic surgery, on the other hand, this benefit seems more subtle to grasp.
In fact, for a long time, it was not measured. It has now been amply demonstrated that cosmetic procedures can have a positive effect on health in very specific areas: posture [2], chronic pain (neck and back pain) [3], smoking cessation [4], improved lifestyle (weight loss, diet, physical activity, with an impact on blood sugar levels) [5], respiratory function [6] and visual field [7]. The psychological benefits of surgery and aesthetic medicine are well established: anxiety [8, 9], quality of life [10], self-esteem [11], self-confidence and sexuality [12]. It has been shown that improving psychological dimensions such as anxiety, self-confidence or self-esteem has an influence on the secretion of stress hormones [13].
There is therefore every reason to believe that cosmetic surgery can directly and/or indirectly improve general health. Ultimately, it is the results of research that are in the process of rendering the ethical question of the benefit/risk ratio of cosmetic surgery procedures meaningless. What remains to be done is to define these benefits in relation to the increasingly simple (and therefore less risky) techniques used. Here again, medical research can help guide ethical reflection on the order of values. At present, public authorities and common sense in general are lagging behind in understanding the usefulness of cosmetic surgery and medicine.
The benefits of surgery for protruding ears in children have long been understood, to the extent that the procedure is now covered by the French health insurance system. For many other indications, there is still a lot of scientific and explanatory work to be done.
Last but not least, it’s important to get to grips with the shortcut that holds that an operation is only useful if it is covered. Here’s a counter-example: dental implants are extremely useful, yet are not reimbursed, barring rare exceptions. Thus, scientific reflection on the usefulness of interventions must set aside, at least temporarily, the question of reimbursement, which does not directly concern it.
Sex conversion surgery
What is (or was) the standard medical course for a French transsexual? We won’t go into too much detail here, just to put things into perspective. The transsexual consults a psychiatrist working as part of a specialised team (with an endocrinologist and a surgeon). The first step is to make a differential diagnosis with the perversions or dysmorphophobias that accompany certain psychoses. Next, an organic work-up is carried out: endocrine work-up, karyotype, radiography, in order to make a differential diagnosis with states of intersexualism. A minimum 2-year psychiatric follow-up is carried out to test the patient’s motivation. This is not psychotherapy, although psychological support may be necessary, as associated depressive states are frequent. This is followed by hormone treatment [14], which is divided into two phases. For male-to-female transsexuals: 6 months of antiandrogen treatment (devirilization) followed by a combination of female hormones (feminization); for female-to-male transsexuals: 6 months of progestin treatment (defeminization) followed by testosterone treatment (virilization).
Finally, at least in theory, comes the surgical stage. For male-to-female transsexuals: castration, vaginoplasty, breast prostheses, facial feminization and other more sophisticated operations; for female-to-male transsexuals: mastectomy, hysterectomy and phalloplasty. The change of civil status (sex and first name) is made by application to the Tribunal de Grande Instance of the place of residence. This procedure takes a year, but often much longer, requires an expert opinion and can be costly for patients who do not qualify for legal aid. The ethical problems are numerous. Let me mention just three:
>>> Recently, French patients have been able to obtain an ALD (affection de longue durée with 100% reimbursement) within a few months of consulting a psychologist just once. A certificate from a general practitioner is sometimes enough to do the rest. All the work mentioned above has not been done.
>>> Requests for reassignment very late in life (over 50) in people who have already had children and, above all, have a morphotype that is difficult to feminise raise questions. I’m thinking in particular of the shoulders, wrists and pelvis.
>>> Child reassignment abuses have recently made headlines in the UK, USA and Australia. The Economist even devoted its front page to the subject in 2020.
Research into cosmetic surgery
When it comes to human experimentation, it’s traditional to distinguish between two periods: before and after the 1947 Nuremberg Code, the result of the trial of Nazi doctors responsible for torturing deportees, under the pretext of “clinical experimentation”. The first article of the Nuremberg Code made consent mandatory for all medical research. In 1949, the World Medical Association (WMA) published its first code of ethics, in which neither consent nor human experimentation were mentioned. In 1964, the same WMA adopted the Declaration of Helsinki, a cautious text which attempted to specify the conditions under which scientific research was compatible with the clinical activity of physicians. Absolute, free and informed consent in “purely scientific” research situations was simply required, on the basis of information left to the discretion of the experimenter, in “therapeutic” research situations.
In 1982, in Manila, the World Health Organization and the Council for International Organizations of Medical Sciences adopted the Declaration of Helsinki, modifying it to make it applicable to disadvantaged and vulnerable populations, on the understanding that the latter were not very scientifically literate, and that consent in such conditions was utopian.
In France, biomedical research was regulated by the law of December 20, 1988, proposed by senators Claude Hurriet and Franck Sérusclat and adopted by broad consensus. Since then, the so-called bioethics laws, their revision and the Jardé law passed in 2012 have completed the protection of people involved in biomedical research. The scientific methodology used to settle most medical questions is often not adapted to surgery, and in particular plastic surgery. Double-blind randomization is difficult in surgery and impossible in plastic surgery.
Placebo surgery” is considered unethical by many of our contemporaries. Others, on the other hand, believe that the price of a false incision can be used to definitively settle important questions and avoid a great many unnecessary operations. Certainly, but let’s not forget that many randomised double-blind studies contradict each other; that’s why research conducts meta-analyses that sometimes contradict each other too!
In the field of surgery, are we ready to consent to so many placebo procedures? Last but not least, placebo surgery is impossible in plastic surgery. As I said in my introduction, it always involves working on form in the physical sense of the term. Another problem is the cumbersome nature of control procedures and the costs they generate. As a result, some surgical research is diverted to less scrupulous countries.
For anyone who can read the international scientific press, the differences are glaringly obvious. One response used by many American and European teams discouraged by legislative inflation is to carry out fake retrospective studies. The idea is to collect information prospectively, i.e. exhaustively, but to publish it retrospectively, as if one had reopened one’s own files. To paraphrase Doyen Carbonnier, who said that too much law kills law, we might well ask whether too much ethics kills ethics. In any case, future revisions of research legislation will need to simplify procedures, without abandoning any ethical considerations. Perhaps more specialised surgical committees would be in order? In love with their operating rooms, surgeons are a rarity on all committees, and on personal protection committees in particular.
Medical education
The general ethical problem of teaching surgery is that of teaching technical procedures to the patient himself. In medicine, dual control is easier. In surgery, at the end of the day, only one person holds the scalpel. For a long time, the great surgical simulator was the anatomy laboratory.
Today, this is still an important tool, but access to it is sometimes very difficult. Fortunately, thanks to advances in technology, simulators using mannequins, physical models or virtual reality are now emerging. They have been the subject of entire sessions at our National Academy of Surgery. The specific problem posed in plastic surgery is that of teaching cosmetic surgery.
In most countries, cosmetic surgery is not practised in university teaching hospitals, so plastic surgeons learn this type of surgery exclusively in the community, without the tools they need to support this learning process. A French cultural exception, cosmetic surgery is taught in university hospitals and is officially part of the internship programme. After that, of course, there’s nothing to stop you continuing your training in the city. Let’s keep it that way.
Conclusion
I often hear people say: ‘It’s not ethical to do this or that’, or even ‘It’s not ethical to think this or that’. I also see people setting themselves up as ‘ethicists’. I would like to remind you that ethics is not law, it is not philosophy, it is not religion and it is not morality. Medical ethics is a dynamic, forward-looking process that always arises from a tension between two propositions, both of which are legitimately defensible, even though we have to make a conscious choice between them. The aim is to encourage reflection on the order of values.
This is nobody’s business, especially not that of ‘ethicists’. I myself have a doctorate in ethics, and yet that does not give me any additional rights, still less the right to say ‘ethics’ as one might say ‘law’. Ethics belongs to the people who are involved in practice, in the broadest sense of the term. From this point of view, we are all equal. The right decision can be made by the humblest person. Ethics are never static. It is a-dogmatic by nature. It evolves with the times, cultures, circumstances and individual cases. Medical ethics tries to base itself as much as possible on objective data, and therefore most often on scientific data, which itself evolves.
This text is partly extracted from a lecture given by the author to the French National Academy of Surgery.
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