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Cosmetic surgery and conscientious objection
  1. Francesca Minerva
  1. Correspondence to Dr Francesca Minerva, Department of Philosophy and Moral Sciences, University of Ghent, St Pietersnieuwstraat 49, Ghent 9000, Belgium; Francesca.Minerva{at}UGent.be

Abstract

In this paper, I analyse the issue of conscientious objection in relation to cosmetic surgery. I consider cases of doctors who might refuse to perform a cosmetic treatment because: (1) the treatment aims at achieving a goal which is not in the traditional scope of cosmetic surgery; (2) the motivation of the patient to undergo the surgery is considered trivial; (3) the patient wants to use the surgery to promote moral or political values that conflict with the doctor's ones; (4) the patient requires an intervention that would benefit himself/herself, but could damage society at large.

  • Conscientious Objection
  • Enhancement
  • Surgery

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Introduction

The literature on conscientious objection in healthcare is mostly focused on cases of doctors who refuse to be involved in morally controversial treatments such as abortion and euthanasia.1 In many countries, doctors are allowed to conscientiously object by a clause in the law regulating the treatment they object to, so that they have a legal right to refuse to perform it or, in some cases, to take part in it. Conscientious objection can be broadly defined as the refusal by a healthcare practitioner to perform a legal medical activity (considered beneficial by the patient) because of concerns about its moral permissibility. Conscientious objection is hence based on the principle that a doctor should not be coerced into being an accomplice in (what they consider to be) wrongdoing.

Conscientious objection is more common in cases of medical interventions that involve highly sensitive activities such as killing (ie, abortion and euthanasia), but there are medical activities that raise moral concerns without involving killing or breaching religious prescriptions. For instance, cosmetic surgeons asked to alter ethnic features of patients who are victims of racism may think that they should not perform such surgeries because, in the long run, this kind of intervention would exacerbate ethnic discrimination.

Given the increasing number and variety of cosmetic treatments performed every year around the world, and given the fact that such interventions are usually not strictly regulated by law, it is useful to look at the ones that could raise moral concerns so as to provide cosmetic surgeons with ethical guidance. I will start by introducing the cases of patients who request cosmetic treatment for motivations I define artistic, whimsical or political. I will then analyse the reasons why a doctor might object to perform such treatments: (1) because the desired surgery does not aim at achieving a goal which is traditionally in the scope of cosmetic surgery, or medicine at large; (2) because the motivation of the patient to undergo the surgery is considered so trivial that it would be unreasonable for him/her to take the risks involved in the surgery; (3) because the patient wants to use the surgery to promote certain moral values that conflict with the doctor's ones; (4) because the patient requires an intervention that would benefit him/her but could damage society at large. Finally, I will discuss whether doctors would have moral reasons to refuse to perform such cosmetic interventions.

Types of cosmetic surgeries a doctor might object to

The general goal of cosmetic surgery is to enhance appearance. An example of a common cosmetic treatment is rhinoplasty performed on a person who has a nose that (he/she thinks) does not fit with his/her facial features.

There are at least two types of cases where doctors can base their refusal to operate on a patient on medical, rather than on moral, grounds: (1) when the surgery is not likely to achieve the goal the patient has in mind because, for instance, the intervention would be too complex to perform for that surgeon or the technology available is not sufficiently advanced and (2) when the patient is affected by body dysmorphic disorder (BDD)i and his/her dissatisfaction with his/her appearance is due to a psychological problem that has to be treated before the surgeon can address the request to perform the cosmetic treatment.

In this paper, I will not discuss cases where the surgeons have medical ground to object to perform the treatment, and I will instead focus on cases where the doctors could ground their conscientious objection on a clash between their values and the patients' ones. In the cases I will discuss, it is assumed that the patients are capable of giving informed consent, meaning that they are competent, they are undergoing the surgery voluntarily and they understand the possible risks involved in the surgery they request. Moreover, I will assume that the interventions are performed in the private sector (as it is usually the case for elective aesthetic treatments), so that considerations about distribution of resources in a public healthcare system are excluded from my analysis.

Cosmetic surgery for artistic reasons

Stelarc is an Australian artist whose performances are based on the idea that the human body is obsolete. Through his art, he wants to show that ‘what it means to be human will not be determined any longer merely by your biological structure but perhaps also determined largely by all of the technology that's plugged or inserted into you’.2 In 2007, he had a prosthetic ear inserted in his arm, and he declared that it took him 10 years to find doctors willing to perform such intervention, because most of them found it immoral to create an ear and implant it in the arm of a patient.

French artist ORLAN underwent nine cosmetic surgeries over 5 years, not in order to look more attractive, but in order ‘to be different, strong; to sculpt [her] own body to reinvent the self’.3 The cosmetic interventions she underwent included the implantation of two horns on her forehead aimed at reproducing the protruding brows of the Mona Lisa.4

It is perhaps not surprising that Stelarc encountered many doctors who refused to develop and insert an ear in his arm. It is indeed reasonable to expect that at least some doctors would feel uncomfortable implanting ears in arms, or horns in foreheads, and help their patients turn into a work of art. However, the fact that cosmetic surgeons feel uncomfortable about a particular treatment does not necessarily provide them with a good reason to refuse to perform it. Elective cosmetic surgery does not aim to cure disease or treat injury, and this is reflected in patients’ expectations and surgeons’ obligations, which may differ from those seen in standard healthcare. In contrast to normal surgery, cosmetic surgery in large part revolves around producing results that are aesthetically pleasing for the patients. It is thus plausible that some patients may request interventions aimed at changing their features in a way that the surgeon might consider against a patient's best interest.

Cosmetic surgery for whimsical reasons

Dennis Avner, also known as the Stalking Cat, underwent 14 interventions in order to look like a feline.5 Among the body modifications he chose to undergo were the bifurcation of the upper lip and a septum relocation aimed at making his nose look flatter.

Mayra Hills is one of the women with the largest breast implants in the world, and each of her breasts weighs 20 pounds. They are so large that she cannot tie her own shoes.6

Herbert Chavez underwent 23 cosmetic interventions over a time span of 18 years, in order to look like Superman. However, his doctor eventually refused to perform more surgeries on him when she realised that he had been injecting himself with illegal fillers; the presence of such substances in his body would have made it too dangerous to perform one more surgical intervention on him.7

The three cases mentioned above seem to differ from the ones of the artists interested in turning their body into a piece of art. One could argue that an artist has a profound thought through motivation to undergo such treatments, whereas the people in the cases just described seem to be motivated by a somewhat shallow and extremely whimsical desire to change features in order to look more like an idealised version of themselves or, perhaps, to look completely different from a version of themselves they do not like or do not identify with. However, the fact that surgeons might feel like this kind of surgery based on trivial motivations conflicts with their beliefs of what is a beneficial treatment does not automatically give them good reason to refuse to perform it. Also, in these cases, if patients are capable of assessing their own preferences, then they have a strong interest in having them satisfied, and the doctors have at least a prima facie duty to satisfy them.

Cosmetic surgery for political reasons

In the paper ‘Women and the Knife: Cosmetic Surgery and the Colonization of Women's Bodies’, Morgan suggested that in order to destabilise the current chauvinist standard of beauty, women could undergo ‘uglifying’ cosmetic surgery, including ‘bleaching one's hair white and applying wrinkle inducing “wrinkle creams”, having one's face and breasts surgically pulled down (rather than lifted), and having wrinkles sewn and carved into one's skin’.8 We can imagine a committed feminist that, after reading Morgan's paper, decides to undergo ‘uglifying’ cosmetic surgery and asks a surgeon to make her nose larger, her lips thinner and her breasts droopy. Doctors might feel uncomfortable performing such uncommon procedures for such an unusual reason, but again, it is not obvious that this implies that they have a good reason to refuse to perform the treatment.

In the next sections, I will discuss what reasons doctors might have to refuse to perform cosmetic surgery requested for artistic, whimsical or political reasons.

Reasons why a cosmetic surgeon might conscientiously object to perform a treatment

Intervention goes against the goals of cosmetic surgery

A cosmetic surgeon might object to perform surgery requested for artistic, whimsical or political reasons because he/she thinks that the goal of cosmetic surgery is to enhance the appearance of an individual.

It is possible that the interventions I have described would not necessarily make the people who undergo them more attractive according to widespread paradigms of attractiveness. But, it may be that according to the specific aesthetic preferences of the same people who require them, such interventions would count as enhancements. It may also be that the interventions are required because these people actually want to look less attractive or just extremely unusual. The point is that there is no good reason to assume that cosmetic surgery should only be used to enhance people's looks. People benefit from having their preferences satisfied, including, quite obviously, when such preferences are different from their doctors' preferences. For this reason, we should protect both morphological freedom and freedom to enhance oneself.9

So, even though the patients might not fix a defect, it may be that they benefit from the surgery in a different way. For instance, artists like Stelarc or ORLAN have surely benefited from the surgeries that have enabled them to express their artistic ideas and to become famous artists, even though such treatments have not made them more attractive, and have not fixed any aesthetic flaw.

Similarly, people who chose to undergo surgery for reasons I have labelled as whimsical, have also benefited from being enabled to follow their whimsical desire. And the feminist who undergoes uglifying surgery may benefit from it because this allows her to make a strong political statement, something she might benefit from in terms of capacity to express her political ideals and perhaps something society as such could benefit from.

If doctors make a conscientious objection to perform cosmetic surgery for artistic, whimsical or political reasons on the sole ground that such interventions do not match the traditional goals of cosmetic surgery, they impose their own idea of what medicine is supposed to achieve. Moreover, they do not take into sufficient account the patient's autonomy by disregarding their assessment of what constitutes a beneficial treatment to them.

The benefits of the surgery do not seem to outweigh the risks

A doctor may refuse to perform cosmetic surgery requested for artistic, whimsical and political reasons because cosmetic surgery, just like any other surgery, involves some risks; hence, it would be an unreasonable choice for the patient who would not use it to enhance a physical feature.

In this case, it would look like the surgeons are grounding their conscientious objection in a medical evaluation: doctors usually help their patients to make decisions by taking into account statistics about the success rate of a certain treatment and weighing them against the benefits and risks involved. However, if doctors refuse to perform the treatment because they believe that, no matter how low the risk involved, it is never worth performing a surgical intervention that (in their view) does not enhance appearance and/or does not increase well-being, then their objection to perform the treatment is not grounded in purely medical reasons, but is instead grounded in their personal values. Although on the surface it looks like the doctor is performing a value-free assessment of the pros and cons of the surgery, if we take a closer look, it is clear that this is not, in fact, the case. The doctor cannot assess the positive value that the surgery might add to the life of the patient, because this is an assessment that only the patient can make (after weighing the risks and benefits). It may be that the whole life of an artist like Stelarc revolves around his artistic performances, and that preventing him from obtaining surgeries aimed at turning him into a piece of art is deeply damaging to his career.

Of course, surgeons should always inform the patients about the risks involved and make sure they understand that the decision to undergo the surgery could have long-term and unpleasant consequences. Surgeons can try to discourage the patients from undergoing a treatment they perceive as unnecessarily risky and, cosmetic surgery being usually performed in the private sector, the doctors have a right to refuse to perform a treatment they might consider inappropriate for various reasons. However, to have a legal right to refuse to do something is different from having a good reason for doing so. My point is simply that surgeons do not have a good reason to refuse to perform the treatment if competent and autonomous patients think that undergoing such intervention is worthwhile and is in their best interest because it satisfies their preferences and increases their level of well-being. Of course, the doctor could disagree and genuinely argue that, for instance, horn implants are outright against one's best interest, even when one asks for them. Given the disagreement, the question about the opportunity of performing the requested treatment boils down to whose assessment of what is in the patients’ best interest should be given more weight: the patients themselves or the doctors. Given the peculiar nature of cosmetic surgery, and its primary goal of producing results the patients themselves find pleasing, it seems reasonable to argue that what the patients believe to be in their best interest should be considered their best interest. This poses a prima facie obligation on the cosmetic surgeons to perform the treatment the patients want even when they disagree with their patients.

The surgery promotes moral values that conflict with the doctor's ones

In the case of cosmetic surgery for political reasons, the doctors could ground their conscientious objection in a conflict between opposing moral values. For example, the doctors could argue that they do not endorse the feminist cause, and they would feel accomplices in wrongdoing if they had to perform a surgery that holds promise for promoting feminist values.

In general, doctors are not justified in imposing their moral (or political) views on their patients. The doctors who would refuse to perform cosmetic surgery on the feminist activist would not have good reasons to put their own moral values before the patient's ones. The most common exceptions to this general rule are the cases of abortion and euthanasia, because they are considered highly sensitive activities. However, as argued before, doctors have at least a prima facie obligation to perform treatments their patients request, even when they do not agree with the goals of the patients, their lifestyle, their idea of what is their best interest and their values. So, in this specific case, doctors would not have a good reason to conscientiously object to perform the uglifying surgery on their patients.

The intervention would benefit the patient but could damage society at large

Margaret Olivia Little10 discusses the cases of cosmetic surgery requested by a patient who feels pressured to meet norms ‘whose content is steeped in injustice’. This could be the case of a non-Caucasian person who wants to undergo surgery in order to look Caucasian, or of a woman who feels pressured into having breast implants to comply with the mainstream idea of sexiness. According to Little, these cases are different from other cases of patients undergoing cosmetic surgery because the norms of appearance in which such requests are grounded are the result of injustice perpetrated against specific groups of people.

If a person requests to undergo cosmetic surgery in order to look less black because black people are discriminated against, then the patient's problem is the fact he/she is victim of racism, rather than genuine discontent with his/her looks. According to Little,11 ‘the moral complication such surgeries present to medicine concerns another relationship altogether––the relation between the surgeon, or indeed medicine as an institution, and the suspect norms and practices themselves’.

Little discusses the hypothetical case of the surgeons who operate under a system of apartheid and feel that performing treatments aimed at making people look Caucasian is a way of endorsing and reinforcing a system they consider unjust. On the one hand, the doctors would be motivated to perform the treatment by the desire to alleviate the suffering of their patients. On the other hand, the doctors would feel complicit in reinforcing norms of appearance that are unjust, hence damaging a larger group of people and society as such. According to Little,12 if a doctor decides to help a patient in such circumstances, they have to do so by maintaining ‘an overall stance of fighting against the system’. She argues that there is a significant difference between the surgeon who promotes and encourages the patients to undergo such treatments, and the one who first tries to help them find alternatives, who does not encourage patients to undergo such treatments and speaks against the social norms that are at the origin of the request for such interventions.

Little suggests that, given the chance that the surgery could alleviate the suffering of the patient, the doctor is morally justified in performing the treatment. But, she seems to suggest that refusing to perform such treatment is also morally justifiable, given that by performing a surgery that reinforces such unjust social norms, the doctor could end up damaging a large group of people (namely, the ones who do not want or cannot undergo the same kind of treatment).13 I agree with Little that a doctor performing surgeries that could reinforce unjust norms would be an accomplice in wrongdoing, but I disagree with the conclusion that this would necessarily justify a doctor's conscientious objection.

If a certain treatment is so damaging to society that, everything considered, it is best to ban it, then society should make it illegal. This is what happened with mutilations of female genitals, which are now illegal in most western countries. If society had similarly good reasons to agree that ethnic surgeries should not be performed because they reinforce unjust societal norms that damage a large group of people, then such interventions should not be allowed in the first place, and it should not be left to the doctor to decide whether to perform them or not. If, however, such treatments benefit the individuals who undergo them to the extent that this benefit outweighs the foreseen damage to society as such, then the doctor should be required to perform such treatments.

In any case, it seems that leaving the decision up to the conscience of the individual doctor is not the best option. Given the current uncertainty about the possibly negative impact of ethnic surgeries on large groups of people, relying on the conscientious judgment of individual doctors can be an acceptable heuristic. At the same time, we need to collect empirical data about short-term and long-term outcomes of such intervention on both individuals and society, and we need to perform an ethical assessment of the pros and cons of such surgeries. Once we have a satisfying understanding of the issue at stake, we can decide whether to allow people to alter their ethnic features or not. And if we conclude that we have no good reason to prohibit such kind of treatment, then doctors would not have a good reason to refuse to perform them on patients who require them (although they would still have a legal right to do so).

Conclusions

In this paper, I have discussed cases of patients requesting unusual cosmetic treatments for unusual reasons. I have considered the request of cosmetic surgery from people who have artistic, whimsical or political reasons to undergo the surgery. I have argued that the cosmetic surgeons could ground their conscientious objection to perform such treatments on four reasons:

  1. The treatment aims at achieving a goal which is not in the traditional scope of medicine and/or cosmetic surgery.

  2. The motivation of the patient to undergo the surgery is considered trivial; hence, the risks do not outweigh the expected benefits.

  3. The patient wants to use the surgery to promote moral or political values that conflict with the doctor's ones.

  4. The patient requires an intervention that would benefit him/her but could damage society at large.

I have examined each of these reasons and argued that none of the first three reasons morally justifies the refusal to perform a cosmetic intervention: According to the basic principle of respect for autonomy, patients are entitled to decide if undergoing a certain treatment is in their best interest. And what constitutes one's best interest is, at least in large part, based on one's own assessment.

In cases where there are considerations about the possible effect of such interventions on society to take into account, we need to collect information about the pros and cons of such interventions, and assess whether the benefits for the individuals who use them are so large that they outweigh the (supposed) damage to society.

References

Footnotes

  • Funding Research Foundation Flanders (FWO).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • i BDD is commonly defined as a psychological disorder in which a person is obsessed with imaginary defects in their appearance.

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