By Rhona Knight
read : Cosmetic Surgery (part 1)
Cosmetic surgery: an ethical issue
Cosmetic surgery is a complex ethical area (See Table 1). With the spectrum of requests, how is it possible to decide what is ethically justifiable?
Papers have sought to address this issue,36,37 but perhaps one of the most helpful publication is the Nuffield Council on Bioethics’ Forward Look Background Paper produced by Donna Dickenson.38 She highlights that what from one perspective can be seen as enhancing freedom of choice to be able to alter one’s body as one pleases, can, from another perspective, be seen as ‘loading new pressure on women and girls (who constitute over 90% of patients) to conform to increasingly stringent and abnormal expectations of what the female body should look like’.39
Implicit in this are feminist arguments against cosmetic surgery. Quoting from an NSPCC qualitative study on sexting, Dickenson gives one girl’s comment on the message sent by the prevalence of pornography: ‘Your body should be like hers for him’.40 The ethical areas she then explores are consent, choice and patient autonomy, the duties of a doctor and the goal of medicine. She also quotes Urban Wiesing, crystallising the key question about cosmetic surgery from the doctor’s perspective: ‘It should not be asked whether a patient should have an aesthetic operation or not, but whether physician should perform it.’41
Imagine the following request by a competent 35-year-old female:
- Breast augmentation for non-existent breasts
- Female circumcision35
- Labial reduction
- Vulval rejuvenation
- Removal of a benign prominent facial lesion
Imagine the following requests by a competent 35-year-old male:
- Hair transplant
- Removal of breast tissues
- Rejuvenating eye lid surgery
Imagine the following requests by parents for their children:
- Surgery for an 8-year-old with prominent ears
- Ear piercing for an 8-year-old
- Circumcision for a female child
- Circumcision for a male child
- Removal of a prominent facial lesion
- Orthodontic treatment for cosmetics reasons
- 16-year-old with 36C breast size wishing breast augmentation
- 16-year-old with 36HH breast size wishing breast reduction
Accepting that consent, choice and patient autonomy are key elements of medical practice, 42,43,44 and that medical practice seeks to minimise harm, the ethical question remains: on what basis can it be decided whether an aesthetic procedure is ethically justifiable, and should be offered or expected as a therapeutic option?
I would like to suggest that weighing the three different parts in the following approach can generally help guide both patient and clinician, whatever their worldview.
Part 1: Where does the ‘concern’ lie on the normal distribution curve? Those with an appearance further from the norm would be deemed more suitable than those closer to the norm.
Part 2: What is the impact of the ‘concern’ on the health and wellbeing of the individual: physical, social, psychological and spiritual? Those more severely affected, following detailed assessment of the impact and failure to adequately improve wellbeing using other methods, for example psychological interventions, would be deemed more in need of a surgical intervention than those with minimal impact on wellbeing.
Part 3: How safe and effective is the procedure? The safer and more effective a procedure, the more likely it is to be ethically justified.
Using this approach, ethical justification for a therapeutic or restorative surgical intervention for people at the extremes of the height distribution curve is less likely due to the risks and poor effectiveness of surgery. Ethical justification for surgical intervention would be more likely for someone with a 40HH breast size, who is experiencing unresolvable social, psychological and physical pain. Ethical justification is less likely for offering rejuvenating or genital surgery for someone near the norm for their age group.
While this framework will aid clinical decision-making and inform patient expectation in the area of cosmetic surgery, it does not deal with the heart of the problem alluded to earlier – the distorted view of beauty, and the concern that much cosmetic surgery is unregulated, financially motivated, and preys on vulnerable people.
Beauty in the Bible
The saying goes ‘Beauty is in the eye of the beholder’. Christians gaze on the beauty of the Lord45 – and many would say that their most powerful experience of beauty is in God himself and in his nature. Most would consider that God’ delights in those who fear him, who put their hope in his unfailing love’.46
The Bible has many references to beauty. There are beautiful women: Abigail,47 Bathsheba,48 Tamar,49 Abishag,50 Esther.51 There are beautiful places52,53 and actions.54 God is seen to hace ‘made everything beautiful in its time.’55 The Bible says that when God made Adam and Eve and completed his work of creation, it was ‘very good’.56 The Bible also tells of future times when ‘The LORD their God will save his people on that day as a shepherd saves his flock. They will sparkle in his land like jewels in a crown. How attractive and beautiful they will be.’57 The God of the Bible is seen to have created a beautiful world and created humans as part of that beautiful world, with the capacity to enjoy that beauty in what is seen, heard and experienced – for example in art, in music, and in other people. Christian are encouraged to take time to appreciate and make the best of what God has given them, whether in caring for gardens, homes, or in clothing. However, the writer of the book of Proverbs reminds the reader that ‘Charm is deceptive, and beauty is fleeting; but a woman who fears the LORD is to be praised’.58 The prophet Isaiah, writing about Jesus some 700 years before his birth, indicated that Jesus ‘had no beauty or majesty to attract us to him, nothing in his appearance that we should desire him’.59
For Christian, beauty is not skin deep. It is about the whole person: heart, soul, mid and strength. It is witnessed to in the life and character of the Christian, described in Paul’s letter to the Galatians as the fruit of the Spirit: ‘Love, joy, peace, forbearance, kindness, goodness, faithfulness, gentleness and self-control.’60
A perfect world
Christians believe that in creation, God made a perfect world without sin, sickness and death, but through sin that perfect world became tainted. In Romans the apostle Paul explains that, ‘The wages of sin is death’.61 He continues, ‘but the gift of God is eternal life through Jesus Christ our Lord’. Christians therefore believe that through the death of Jesus on the cross, the wages of sin have been paid. Through the resurrection of Jesus the tainted and fallen world is in the process of being restored, with the future promise of a new heaven and earth, with no more death, crying, tears or pain – where all things will be made new.
Thus, while Christians believe God is at work in the world, and in the lives of Christians, transforming and restoring, enabling them to become more like Jesus, sickness, ageing, death and decay are still part of our lived experience. Thus Christians seeking to follow Jesus’ footsteps strive to bring healing and release, and to promote holistic wellbeing63 Love is all its fullness.64
The image of God
The emphasis of the Bible is that all human beings are made in the image of God. It is not about how people look but who they are in God – created and loved, with the hope of being transformed into the likeness of Christ. ‘Knowing who we are and who we are intended to be helps us to resist the cultural pressures to find our deepest identity in the images and ideals of perfection that we see all around us.’65
Christians, considering their own approach to cosmetic surgery, may find themselves agreeing with Richard Poupard, who warns that ‘we should be discerning regarding our motivations for pusuing cosmetic plastic surgery… we should be careful if our motivations for surgery are principally to increase our self-esteem.’66 They may also find it useful to reflect on the motivation underpinning the desire or need for cosmetic surgery. Is the motivation to promote Christ-likeness? Is it to enable the best use of the gifts they have been given? Or is it about seeking identity or security in our own image?
This does not mean that Christians are opposed to cosmetic surgery. Indeed, as in the ethical framework described earlier, the Christian seeking to promote healing, health and wellbeing would probably be happy with most therapeutic and restorative interventions. They may find themselves advocating for those denied much-needed cosmetic surgery. They may also work to encourage the development of national and international standards in this whole area, looking also to see how similar approaches can be applied to other interventions, for example orthodontics.
For most, the world’s concept beauty in unattainable. Even the most highly paid models have their ‘imperfections’ airbrushed out. Yet 1 Peter 3:3 tells us that in God’s eyes, ‘Your beauty should not come from outward adornment, such as elaborate hairstyles and the wearing of gold jewelry or fine clothes. Rather, it should be that of your inner self, the unfading beauty of a gentle and quite spirit, which is of great worth in God’s sight. ‘While man may look at outward appearance, God looks at the heart.67
Rhona Knight is an academic GP in Leicestershire.
35. African Doctor: ‘Is female circumcision so awful?’ Jezebel, 30 November 2007 bit.ly/bkm3Fo
36. Mousavi SR. The Ethics of Aesthetic Surgery. J Cutan Aesthet Surg 2012;3(1):38-40 1. usa.gov/18T10l1
37. Atiyeh et al. Op Cit
38. Dickenson D. Aesthetic/Cosmetic Procedures Background Paper. May 2013 bit.ly/18T1iyR
39. Dickenson D. Op Cit:5
40. Ringrosse J, Gill R, Livingstone S and Harley L.A qualitative study of children, young people and ‘sexting’. London:NSPCC. 2012:40
41. Wiesing U. thical aspects of aesthetic medicine. in Prendergast PM and Shiffman MA (eds.) Aesthetic Medicine. Berlin: Springer, 2011:7-11
42. GMC. Consent: patients and doctors making decisions together (guidance for doctors). GMC, 2008 bit.ly/njae6a
43. GMC. 0-18 years: guidance for all doctors. GMC, 2007 bit.ly/18qXpol
44. Barratt H. Autonomy – who chooses? CMF File 29, 2005 cmf.li/1jpyOwu
45. Psalm 27:4
46. Psalm 147:11
47. 1 Samuel 25:3
48. 2 Samuel 11:2
49. 2 Samuel 13:1
50. 1 Kings 1:3
51. Esther 2:2
52. Jeremiah 3:19
53. Jeremiah 6:2
54. Matthew 16:10
55. Ecclesiastes 3:11
56. Genesis 1:31
57. Zechariah 9:16-17a
58. Proverbs 31:30
59. Isaiah 53:2b
60. Galatians 5:22-23
61. Romans 6:23
62. Revelation 21:5
63. Luke 4:16-19
64. John 10:10
65. Winter R. Perfecting Ourselves to Death. Downers Grove: InterVarsity Press, 2005:161
66. Poupard RJ. Self-Esteem from a Scalpet: The Ethics of Plastic Surgery. Christian Research Journal, 2010:33(4)
67. 1 Samuel 16:7
Christian Medical Fellowship (CMF) Files No. 52, 2013