Ethical Implications of Plastic Surgery Over Time

The cosmetic procedures plastic surgeons performed have fallen under scrutiny by many since their inception for the circumstances under which a doctor must operate on their patient. Without medical diagnosis or recommendation for surgery, the legitimacy of aesthetic procedures has been controversial in the medical world for several reasons. Some claim that operating on patients who are otherwise healthy goes against the internal morality of medicine, violating the idea that we must “do no harm.” [1] Some argue that the consumerist nature of cosmetic surgery, heavily promoted by marketing and advertising, goes against inherent values of medicine, which is not a simple business, but instead operates on a higher, more noble platform. [1] Others believe that we should embrace procedures to remove all processes that are responsible for “producing pain and misery to the body and mind.” [2] Given the nature of plastic surgery, especially cosmetic surgery, the history of its development and acceptance has much to teach us about bioethical principles such as patient autonomy, informed consent, and patient exploitation.

The “Father of Plastic Surgery” was an Indian man named Sushruta. His understanding of anatomy, pathophysiology, and innovative ideas for therapeutic interventions were unparalleled for his time. Around 1000-800 BC, Sushruta lived in what was known as the “golden age” of medicine, a time where medical advancement and innovation in ancient India was thriving. Perhaps his most notable innovation was his development of techniques for rhinoplasty. Sushruta was a pioneer of his time and some of his methods and tools are still in use today. Sushruta revealed the details of his work, methodology, and beliefs on ethics through writings called Samhitas. In his writing, he discloses various techniques for procedures. He describes how to use a creeper leaf as a stencil for the amount of buccal skin that is needed for the rhinoplasty procedure. Then, after scarifying the nose with a knife, he utilizes the large head of ants to sew the dermal layers of the cheek with the nose.

Why was there a need for rhinoplasty in ancient India to begin with? Interestingly, ancient India along with other civilizations throughout history have implicitly utilized the nose as a symbol for integrity and decency. In ancient India, a common punishment for breaking the laws of the time (most commonly, adultery) was to publically chop off the “criminal’s” nose. In this, the sanctity of a person’s private world was violated in a humiliating way--a visible reminder in the middle of the face, difficult to conceal, carried forever.

These methods for rhinoplasty remained unknown to the West for several hundreds of years. In the late 16th century, Gaspare Tagliacozzi of Bologna, Italy wrote the first book that was exclusively devoted to plastic surgery. This book was revolutionary because it had a scientific basis and, before its release, the methods for cosmetically improving a damaged nose were kept proprietary by the families of barber surgeons. Furthermore, Tagliacozzi lived in a time where there might have been social or religious pushback on the surgical alteration of the appearance of the body. Tagliacozzi achieved remarkable outcomes for his time, using the arm as the skin donor and recommending that the patient reach “manhood” in order for the skin to be able to withstand operation. [3]

Before the emergence of cosmetic surgery, the development of plastic surgery was slow. This was partly due to the lack of anesthetics to manage the pain until 1846 when ether and chloroform were discovered. Another hindrance was the lack of antisepsis, which was not introduced until 1867. If the patient was able to tolerate the pain, survive the loss of blood and potential shock, the chance of infection developing prior to this time was almost guaranteed. Furthermore, the idea of sickness was tied to a person’s self-worth and decency. [4] The body was thought to be a physical manifestation of a person’s relationship with God. Thus, if a person contracted leprosy or syphilis, it was a mark if punishment by God. Surgery would have intervened, and thus erased the sinner’s divinely-designated branding.

The status of a plastic surgeon was lowly until the 17th century. It was then that the combination of medicine with science revitalized the surgery field. The medical science helped subdue prior notions that the body was somehow attached to a person’s morality. However, it was not until the Crimean war and both world wars that plastic surgery rose as a notable profession. Improved techniques develops from the reconstructive efforts that were the result of war. [4] Plastic surgery’s reputation improved from that which intervened with God’s plan to that which aided heroes. As surgical technique and methodology grew, so did the field of plastic surgery. Eventually, the patient base went from disfigured heros to patients with defect, illness or accident-related reconstructive needs to patients with the desire to change the way they look. This change came with the advancement of techniques and technology to improve outcomes in plastic surgery.

Although one may argue that humans have been changing the way they look since the beginning of time, the emergence of cosmetic surgery in the field of plastic surgery rose has surged in popularity within the last century. [5] In the 1950’s doctors started utilizing polyvinyl sponges in order to enhance breast size, although there were many complications, these were far less outrageous than the ivory, glass ball, and ground rubber implants of earlier in the century [6]. In the 1960’s, the silicon breast implant provided a much better alternative. Today, breast implants, along with several other cosmetic procedures, are widely popular around the world. Between the years 2000 to 2016, the number of breast augmentation surgeries has increased 37% in the United States, while the number of botox injections has increased from about 787,000 in 2000 to over 7 million in 2016. [7]

Despite the fact that the nature of plastic surgery has changed throughout history, one thing remains the same: humans have always associated meaning to the way they look. Whether the body be a medium to expose crime, a connection to God, or a reflection of the way a person feels from within, the physical appearance has always been important to humans. Plastic surgery has given people the ability to have autonomy over the way they look--but not without criticism. Some argue that the idea of “improvement” in cosmetic surgery upholds culturo-normative standards [8]. Others say that it is possible to take advantage of patients through the market model of medicine. As the physician, the seller has an immense privilege of medical knowledge that could be misconstrued to the consumer for profit-driven motives. This disparity in knowledge could make it difficult for physicians to provide adequate information for patients to properly provide informed consent. [8] Lastly, the medical principle of health equity is challenged as the psychologic basis for obtaining cosmetic surgery is not recognized, providing access to only the wealthy.

The current ethical issues around cosmetic surgery are patient exploitation and informed consent while respecting the patient’s autonomy. Historically, plastic surgery has been performed as a byproduct of an illness, deformity, or accident. Today, it is acceptable to perform cosmetic procedures on otherwise healthy patients. As the healer, the responsibility of the physician is to fully inform the patient and make sure the patient is undergoing surgery for the right reasons -- in a proper state of mind, and wholly aware of the potential risks. The motive should not be to gain a profit, but instead to help the patient achieve their goals, physically and psychologically. Although I feel that it is completely reasonable for a person to change the way they look, it is the duty of the physician to make sure that the patient is not exploited. [1]

As technology advances and we are able to do more for people, how do we maintain our ethics? Should they change as society changes, or should they be unwavering? I have learned that it is difficult to stop progress, and I do not think that we should not have to. However, as times change it is important to consistently look back at our history, learn from the past, and make sure that our sense of purpose remains strong. Our responsibility and commitment to the our duties as physicians should prevent us from using our knowledge to capitalize on the potentially vulnerable patient.

Plastic surgery has inexplicably advanced and evolved into a field of medicine unlike others – combining aesthetics and art into medicine. Of course, there are conflicting opinions that are associated with cosmetic surgery. However, understanding how plastic surgery has changed over time and society as a collective whole has reacted to such changes is an area for learning about ethical issues in medicine and why they are of value.

References:

(1) Miller, Franklin, Brody H, Chung Kevin. Cosmetic Surgery and the Internal Morality of Medicine | Cambridge Quarterly of Healthcare Ethics [Internet]. Cambridge Core. Cambridge University Press; 2000 [cited 2017 Jun 23]. Available from: https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S0963180100903074

(2) Sorta-Bilajac I, Muzur A. The nose between ethics and aesthetics: Sushrutas legacy. Otolaryngology-Head and Neck Surgery. 2007;137(5):707–10.

(3) Tomba P, Viganò A, Ruggieri P, Gasbarrini A. Gaspare Tagliacozzi, pioneer of plastic surgery and the spread of his technique throughout Europe in "De Curtorum Chirurgia per Insitionem". [Internet]. European review for medical and pharmacological sciences. U.S. National Library of Medicine; 2014 [cited 2017 Jun 23]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24610608

(4) Davis K. Reshaping the female body: the dilemma of cosmetic surgery [Internet]. New York: Routledge; 2008 [cited 2017 Jun 22]. Available from: https://books.google.com/books?hl=en&lr=&id=3b9YAQAAQBAJ&oi=fnd&pg=PP1&dq=first cosmeticsurgery&ots=pM_stauYqJ&sig=hmQpygPAcCui7MIC4GEyBmD1E9I#v=onepage&q=india&f=false

(5) AAFPRS - Facial Plastic Surgery Today [Internet]. Facial Plastic and Reconstructive Surgery | Alexandria, VA. American Academy of Facial Plastic and Reconstructive Surgery; 2008 [cited 2017Jun23]. Available from: https://www.aafprs.org/patient/fps_today/vol22/04/pg1.html

Fourth Quarter 2008, Volume 22, Number 1

(6) Bondurant S, Ernster V, Herdman R. Safety of Silicone Breast Implants. [Internet]. National Center for Biotechnology Information. U.S. National Library of Medicine; 1999 [cited 2017Jun23]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20669503

(7) Glatt BSB. Annals of plastic surgery: Long-term follow-up of a sponge breast implant and review of the literature. 02/1999;42(2):196.

(8) 2016 Plastic Surgery Statistics [Internet]. 2016 Plastic Surgery Statistics Report. American Society of Plastic Surgeons; 2017 [cited 2017Jun23]. Available from: https://www.plasticsurgery.org/news/plastic-surgery-statistics

(9) Mousavi S. Ethics of Aesthetic Surgery. Journal of Cutaneous and Aesthetic Surgery. 2010Jan;3(1):38–40.