Published online: July 25, 2017
Recently, a surgical intervention called the Ilizarov procedure was conducted in Hyderabad for the purpose of enhancing height. What made this interesting and newsworthy was the fact that the individual in question was of a stature that was considered normal in his culture. In a very well-argued paper, Vishwanathan and Nimbalkar (1) respond to press reports and an ongoing debate about whether this surgery should indeed have been performed and also, whether the individual’s parents or family should have been part of the decision-making process.
They are, I think, completely correct in opining that according to the existing ethical guidelines, the surgeons were well within their rights in conducting the surgery. They validly point out that according to the current understanding of the tenets of autonomy, justice, beneficence and non-maleficence, the surgeons can hardly be faulted for taking the decision to operate. The authors do a very good job of explaining these ethical issues.
The question that remains is this: in the context of the current debate, can we attempt to unpack these concepts further? To begin with, I would like to thank the authors for their paper. I have been fascinated and intrigued by the many questions that were raised. In the past few months, I have been discussing this with friends, professional colleagues, family members, and in an online psychiatry mailing list. The commentary that I write draws upon a combination of these discussions and my thoughts on the matter.
One way of looking at the matter is to reframe the question: given the existing medical and ethical guidelines, were the surgeons’ actions justified? The answer to this particular question would, as Vishwanathan and Nimbalkar point out, clearly be in the affirmative.
The two other questions that I believe need to be raised, however, are:
The only reason for which I raise the first question is that this is one aspect that the press reports were critical of. In my opinion, it is clear in this case that when confidentiality has been requested, it would be a breach of ethics to act contrary to the wishes of the client. This, however, presupposes that the surgeon has suggested that the client should discuss the matter with the family members or friends concerned. If the surgeon has suggested this and the client has clearly expressed the desire that the parents, family or friends not be contacted, then, given the fact that the patient is an adult, it would be fine not to seek the parents’ approval.
As far as the second question is concerned, given the current understanding, the surgeons can hardly be blamed, contrary to what was implied in the media reports. This is because when it comes to surgery for reasons other than therapeutic, there are no guidelines to help the surgeon decide on the “desirability” or otherwise of surgery.
The question for the ethicist, however, should perhaps be neither of these, but: what should the medical and ethical guidelines in such a situation be? If we are to consider the issue from this perspective, we may perhaps open up a somewhat different area of enquiry.
As we are aware, a fairly large number of people who undergo cosmetic surgery do so to feel better about themselves. Clinical experience tells us that for many of those who undergo surgical intervention, the results are actually far from desirable. This is in part because if the wish to access the surgical procedure arises from a body image disturbance, it is extremely unlikely that the surgical intervention will have the desired effect (2, 3).
As a practising psychiatrist, I have on my client list a number of people who have undergone surgeries for cosmetic reasons and have not benefited from the results. There are also a few who have undergone repeated surgeries. While there is little systematic literature on how many of the people who approach the surgeon for cosmetic surgery have a body image disturbance, there remains the real possibility that at least some will resort to surgery. It, therefore, makes sense to establish a more systematic mechanism to ascertain how many people actually suffer from such a problem. The guidelines on cosmetic surgery should perhaps include a prospective follow-up, which is sensitive to the psychological outcome, of clients who undergo cosmetic surgery.
If one is to accept this premise, then one needs to make a more nuanced assessment of the psychological state of the individual requesting such a procedure, and discuss the person’s expectations from such a procedure.
During the assessment before such surgery, it may be fairly straightforward to rule out the more obvious psychiatric illnesses, such as a clear depressive disorder, a psychotic illness, or obsessive thinking patterns, but disturbances in body image present a slightly more complicated challenge. Whereas in the case of a clear pathological construct, such as dysmorphophobia (4) or body image identity disorder (5), it may not be too difficult to identify the issues that need to be addressed, in less obvious conditions, such as “height dysphoria”, or “body image dysphoria”, the issues may not be so clear.
Sex reassignment surgery could be another avenue of exploration. The history of interventions for what is called gender dysphoria has perhaps a lot to teach us. Despite the fact that such surgery has a long history, precise data on its long-term psychiatric morbidity and mortality remain both scant and contradictory (6). For this reason, the World Professional Association for Transgender Health, which regularly updates its guidelines, suggests that detailed and sensitive psychological assessment and evaluation should form an integral part of the standards of care in the clinical care guidelines for transsexual, transgender and gender non-conforming persons (7). It has also become clear that a significant number of people who undergo sex reassignment surgery have several psychological and mental health problems. In fact, it is in recognition of this fact that it has come to be accepted that psychological support is an integral part of the management of what is called gender dysphoria.
It is clear, then, that merely suggesting a routine psychiatric or psychological assessment before planning a cosmetic surgery would yield little or no benefit, if the assessment is restricted merely to “ticking boxes”. In fact, here again, one can make a clear analogy with gender reassignment surgery. It seems obvious that any individual contemplating such a surgery would benefit from psychological support, but such support is not easily available.
On a different note, a person’s satisfaction or dissatisfaction with his / her body image is, to a large extent, influenced by sociological constructs (8). In discussions about psychological pressures, media influences, societal impacts or peer group dynamics, it is taken for granted that the individual’s autonomy is unarguably intact. Compromised insight and autonomy in conditions such as body image identity disorder (9) are seen as somehow qualitatively different from body image dissatisfaction or dysmorphia. If, however, one were to argue for a quantitative difference and view these conditions as part of a continuum, it may open up a slightly different perspective. While this article certainly does not suggest that all shades of body image dissatisfaction be viewed through the lens of mental illness, it is possible that it may be problematic to look at them only through the sociological lens and dispense completely with the clinical gaze (10).
It may also be worthwhile to separate the “medical ethics”, as it were, from the “societal ethics”. What the paper and the commentary focus on are the medical aspects of the ethics discussion. As the world moves rapidly towards a free market and capitalist framework, there is a real possibility that medicine and medical technology can and will become an implement (not necessarily unwilling) of a marketing enterprise that is driven by the consumer’s desires. The nature of the political economy of health, and the impact of this on the way that disease, disorder and the provisioning of health service is conceptualised, are very important points of discussion. The question of the inevitability of that change, and the agency and choices that medicine itself has to engage with in the discourses around this are out of the scope of this commentary, but are issues that need to be flagged.
In summary, my opinion would be that in this specific case, I do not think that any existing ethical guidelines were violated. However, it may perhaps be time to start a discussion on whether there should be guidelines for providing both psychological assessment and support for surgery of this nature. One would obviously also have to keep in mind the availability of such support. It may also be a good time to initiate discussions on the nature of these choices.
I am grateful to the discussions in the mailing list Indian_psychiatry@yahoogroups.com that gave me a fresh perspective.
I would also like to acknowledge the many critical inputs from Aditya Sarin that helped to refine, sharpen and, indeed, re-evaluate many of the perspectives presented.