Altering human physical appearance is as old as recorded history. Evolutionary biologists have linked our desire for altering the body to innate biological drives for partner selection and reproduction. We currently stand at a unique point in the history of such practices. Our unprecedented ability to alter human appearance raises new questions about the nature of non-therapeutic, cosmetic surgery, and the justification for altering the body for purposes other than to cure diseases. Science and technology offer us genetic engineering and gene therapy, prosthetic limbs and brain computer interfaces that change what we mean by human enhancement (1).

People have often questioned the justification for undergoing surgery to alter appearance rather than to cure infirmity. Many studies have failed to demonstrate the safety and long-term efficacy of certain cosmetic surgery procedures. There are additional risks in surgeries of long duration and in multiple surgeries. There is little work in this field on issues such as surgical experimentation and innovation; nor has it drawn up accepted guidelines of practice (2). Such issues are important because implicit in the practice of cosmetic surgery is the notion that physical beauty as defined by certain social norms is not only a goal to strive for, but also a goal for which one might undergo a potentially risky procedure. There is also the question of whether cosmetic surgery should resist or cater to a patient’s desires (3).

Enhancement versus therapy

Ethical arguments in support of cosmetic surgery have focused on the notion of altering the human form for benefits that lie on the hazy boundary between enhancement and therapy (4). Others view the pursuit of aesthetic improvement as either a personal vanity or a lamentable submission to the superficial priority placed on appearance in a corrupted society (5).

Major questions arise from these tensions. Should cosmetic surgery be a matter of consumer desire alone, that does not need medical justification? Is it then removed from the realm of medicine as we commonly understand it? As it becomes more widely used one must ask: what are appropriate or "correct" applications for such surgery? When is it inappropriate? Should cosmetic surgery be used to help people conform to media messages of what is considered beautiful? Given that beauty is defined by the culture dominant within a society, should cosmetic surgery be used to change ethnic traits? Does cosmetic surgery violate some notion of justice when it is available only to those who are wealthy? Should there be guidelines for the use of cosmetic surgery on children and teenagers? Should there be an age for consent to such procedures? While there are no definitive answers to these questions they are of critical importance today with the increase in cosmetic surgery in ethnic alteration, and with the emergence of new possibilities. It is thus essential to define the legitimate and illegitimate uses of cosmetic surgery (6).

Beneficence and nonmaleficence

Beneficence means an ethical duty to maximise benefit. Non-maleficence refers to the duty to reduce risk. Physicians have a duty not only to avoid harm to the patient but also to weigh the risks of the surgery with the needs of the patient and to offer a plan that will provide him or her maximum benefit. If patient benefit is not the ultimate outcome then the principle of beneficence is violated. Taking this argument forward, one must ask whether catering to the patient’s desire for cosmetic change is in the patient’s best interests. It is challenging to apply this principle with respect to cosmetic surgery. Measuring benefits like long-term outcomes and quality of life is difficult and few studies on the long-term positive effects of cosmetic surgery exist (7).

Risk is the probability of negative consequences of a desired action. All surgery involves risk and this risk must be fairly well defined before surgery is undertaken. While cosmetic surgery may involve relatively modest risks, they do exist. Professional groups must work to ensure, to the extent possible, that such surgeries are held to the highest medical standards and complications minimised. The profession is also responsible for ensuring that the public is always informed of all the risks involved. The lack of self-regulation and the increase in ambulatory clinics have increased the risks faced by people undergoing cosmetic surgery. There is a need to maintain professional standards and regulate the practice of cosmetic surgery (8).

Autonomy

The principle of autonomy is based on the idea that we have the capacity to make choices. We have the right to determine what will happen to our own bodies. Patient autonomy is made up of negative and positive freedoms. The negative freedom is freedom from coercion by others; positive freedoms are those that allow self- determination, self-expression and choice. The patient must not only have the ability to say "No" but must also be sovereign in his or her decision-making capacity. All cultures and races have their concept of beauty. The need to conform to that norm may put so much pressure on a person that he or she feels compelled to undergo cosmetic surgery. In some ways, the media and social pressures work together to force the decision to undergo cosmetic surgery. The principle of choice may apply to all aspects of healthcare. A fundamental question is whether cosmetic surgery constitutes healthcare. Some have viewed the practice of cosmetic surgery as outside traditional medicine (9).

Informed consent

Informed consent must be obtained from the patient before any medical intervention. There is an important distinction between ethically obtained informed consent and legally effective consent. Ethical consent denotes a decision-making process based on mutual respect and full disclosure; it describes an interaction between doctor and patient over time, one that is more than just getting a signature on a consent form. The patient must be informed about the procedure by the surgeon himself. Patients must be given enough time to assess risks, make decisions and ask all the questions they wish to ask. They should never be pressured to make a decision before they are ready.

Well informed patients will have fewer anxieties during surgery and better compliance with instructions. They cope better with complications and express greater satisfaction with the results of surgery.

The success of informed consent is largely based on effective communication between doctor and patient and the ability of the patient to understand what is being communicated. This process can often fail because of the doctor’s poor communication skills or because of the patient’s preconceived notions and expectations (10).

Surgeons also have the responsibility to rule out major psychiatric disorders in their patients. At the very least, they must refer patients to a mental health professional prior to surgery. It is possible that some psychiatric patients have a diminished autonomy and decision-making capacity. Surgeons therefore have an ethical responsibility to make that determination before conducting surgery.

Corporate medicine

The influx of managed care in the US has encouraged medical professionals in various specialities to treat medicine as a business. Cosmetic surgery, too, is treated as a commodity. India is no exception to this trend. False and misleading advertisements flourish in the media and on the internet in the fight for a share of the market, and the patient’s welfare becomes second priority as gimmicks are promoted in the name of scientific development. This also raises questions about the nature of voluntariness and full disclosure (11). Even if one believes that cosmetic surgery can help in the promotion and maintenance of health, such commercialisation is contrary to efforts to make the discipline a legitimate medical practice (12).

Research

As in any medical and surgical specialty, cosmetic surgical procedures should be subjected to rigorous research protocols before they are used on patients. Any clinical research initiative in cosmetic surgery must adhere to the highest standards of research subject protection. The line between surgical innovation and human experimentation is a murky one. The emphasis must always be on safeguarding the health and welfare of the patients involved.

There is very little regulation of the use of specific products for cosmetic surgery purposes. There is relatively little monitoring of the efficacy and safety of cosmetic surgery procedures and treatments and only limited mechanisms to prevent the use of demonstrably harmful procedures exist.

The media

Cosmetic surgery has increased in the last decade. Not only has its popularity soared but media coverage has also increased. Media promotion of cosmetic surgery makes it more acceptable for individuals to use it to improve their appearance. Consequently, consumer pressure is responsible for the growth of cosmetic surgery. Cosmetic surgery is the most prominent example of a new focus on lifestyle medicine in which tools that were earlier viewed as appropriate for therapeutic goals are now finding application as consumer products. This also leads us to consider our quest for perfection at an individual and societal level. It also provides an avenue to consider the limits of capitulation to consumer desires. Parents may request cosmetic changes in the physical appearance of their children with Down’s syndrome but this surgery does not mask the cognitive deficits that would persist in the child. We must make sure that cosmetic surgery is used to enhance one’s self image and well being and that it meets the intended goal while minimising risks to the patient (13).

Definitions of normalcy

The goal of cosmetic as opposed to reconstructive surgery is to improve the appearance of an individual who has an abnormal appearance. Some argue that normalcy cannot be operationally defined and it depends on the individual’s subjective perception. The judgments of normalcy lie on a continuum and may be viewed differently not only by the individual but also society. A cleft lip may be viewed by society as abnormal in appearance and corrective cosmetic surgery may be encouraged in such cases. A prominent nose may not be considered abnormal by society but for the individual, it may be unacceptable enough to prompt him or her to undergo surgery. Adolescents experience much emotional turmoil as part of their psychosocial development. When teased about physical qualities that do not conform to the norm, they may experience sufficient suffering to consider surgery as a solution. Teenage breast augmentation is no longer a very unusual procedure in some parts of the West. The clear ethical mandate is that cosmetic surgery on adolescents should be discouraged in general and taken up only if there is a compelling need and after thoughtful consideration (14).

Conclusion

I have tried to examine the ethical issues in cosmetic surgery in this article. The increases in demand of this type of surgery and the advocacy of practice in the media have raised concerns about the circumstances under which cosmetic surgery is ethical and permissible. The steps needed to improve the ethical practice of cosmetic surgery are very clear. Scientific evidence of the safety and efficacy of cosmetic procedures and devices is needed to assure the public that the interventions being offered have been evaluated properly for their efficacy and safety. Certification of cosmetic surgeons and a closer regulation of cosmetic surgery facilities will increase quality and protect patients. The potential for the abuse of cosmetic surgery must also be considered. It is a good example of the need to balance beneficence and autonomy. A patient desiring cosmetic surgery should not be assured of getting it on the strength of that desire alone. The surgeon should decline such a request if it is felt that the patient will not benefit from the surgery or is not mature enough to understand the ramifications of the procedure. Surgeons must be cognisant of their actions when conducting a cosmetic surgical procedure that may enforce a cultural norm. We must respect cosmetic surgery but be wary of its overuse. The eternal questions are whether cosmetic surgery can contribute to making us content with ourselves and what it is that we aim to achieve by altering ourselves and our bodies.