Cosmetic surgery and the internal morality of medicine.

Cosmetic surgery is a fast-growing medical practice. In 1997 surgeons in the United States performed the four most common cosmetic procedures — liposuction, breast augmentation, eyelid surgery, and facelift —443,728 times, an increase of 150% over the comparable total for 1992.1 Estimated total expenditures for cosmetic surgery range from $1 to $2 billion.2 As managed care cuts into physicians’ income and autonomy, cosmetic surgery, which is not covered by health insurance, offers a financially attractive medical specialty. Although increasingly popular, cosmetic surgery is a most unusual medical practice. Invasive surgical operations performed on healthy bodies for the sake of improving appearance lie far outside the core domain of medicine as a profession dedicated to saving lives, healing, and promoting health. These cosmetic procedures are not medically indicated for a diagnosable medical condition. Yet they pose risks, cause side effects, and are subject to complications, including pain, bruising, swelling, discoloration, infections, formation of scar tissue, nerve damage, hardening of implants, etc.3 Moreover, cosmetic surgery is a consumer oriented entrepreneurial practice, heavily promoted by advertising in newspapers, magazines, the yellow pages of the telephone directory, and by marketing on the World Wide Web. The remarkable nature of cosmetic surgery is reflected on in the following comments of a plastic surgeon: “But then on top of it all we actually operate on people who are normal. It’s amazing that we’re allowed to do that, the idea that we can get a permit to operate on someone who is totally normal is an unbelievable privilege.” 4 Is cosmetic surgery a medical privilege or an abuse of medical knowledge and skill? With the exception of feminist scholarship, which focuses on the personal and social meaning and value of cosmetic surgery for the lives of women, the bioethics literature has neglected to pay attention to moral issues posed by cosmetic surgery.5 In this article we examine cosmetic surgery from the perspective of professional integrity and the internal morality of medicine —a perspective that we have explicated and defended in two previous essays.6