Plastic surgeons must become ‘mothers at conscience.’ Here’s why.

By: Alexander Zuriarrain MD, FACS

“We restore, rebuild, and make whole those parts which nature hath given, but which fortune has taken away. Not so much that it may delight the eye, but that it might buoy up the spirit, and help the mind of the afflicted.”

Does the quote sound familiar? It should, because the words, written in 1597 by Italian surgeon Gaspare Tagliacozzi, considered the pioneer of plastic and reconstructive surgery, remain the philosophical and ethical underpinning of our surgical subspecialties. Yet, as many experts in our profession contend, this modern era of ongoing—and sometimes not fully tested—surgical innovations, exaggerated societal norms of what constitutes beauty, and unbridled use of social media continues to vex us—and our decision making—in patient-physician relationships.

In an article published in the AMA Journal of Ethics, the writer proposes that social media sites depicting the “beauty” of celebrities, “sexiest man” competitions, and unreal reality TV shows like “Extreme Makeover” have thrust plastic and cosmetic surgery into prominence, while putting light on “interesting” ethical questions. Might not some surgeons be complicit in “perpetuating harmful or unattainable standards of appearance?” the writer asks.

 Does the patient have the ultimate “right [and authority] to decide what happens to his or her body,” even if what the patient is seeking cosmetically is risky, not in the patient’s best interests, or unrealistic?

Even more perplexing is what the author of the AMA ethics article calls “ramifications of appearance.” Does a patient’s anxiety, lack of self-confidence, impaired social functioning—even career success—based on personal perception of “flawed” looks—constitute a legitimate medical condition” requiring surgical treatment? “Answering the question requires differentiating between the delivery of needed therapy and…the medicalization of consumer dissatisfaction,” the author asserts.  

Although cosmetic surgery can enhance a patient’s quality of life, some experts caution against plastic surgeons placing themselves in the role of psychiatrist by delivering services simply as a way of improving patients’ state of mind and overall mental health.

The Four Guiding Principles of Ethics

Ethics analysts writing in a 2021 issue of the journal Plastic and Reconstructive Surgery argue that, as aesthetic and plastic surgeons “continue to push boundaries and develop increasingly complex treatments,” acknowledgment of ethical concerns raised by this advancement of science is paramount. 

“Surgical ethics in the United States is based on the moral theory of [core principles],” they state. Those principles are:

  1. Autonomy of the surgeon to provide services and that of the patient to make personal decisions based on transparent, accurate, and truthful information provided by the surgeon.
  2. Beneficence: Providing benefit to the patient by considering the most appropriate treatment options.
  3. Nonmaleficence: Minimizing patient risks and complications
  4. Justice: Making high-quality services and resources available to all patients—not just to the wealthy.

These same study authors suggest “prominent developments in plastic surgery and greater public exposure to the specialty have created new ground for ethical predicaments. Rising rates of gender-affirmation surgery, female genital cosmetic surgery, and vascularized composite allograft transplantation represent a sample of new trends that fall within the expertise of a plastic surgeon.”

Experts authoring another 2021 article in Plastic and Reconstructive Surgery contend “the decision to offer an innovative procedure should depend on the patient’s goals and expectations, the surgeon’s experiences and incentives, the operative risks and available alternatives, and the impact on society.” They also call for the “safe spread and adoption of [evidence-based] surgical innovations.”

Responsible Use of Social Media

Meanwhile, use of social media to communicate with, and market directly to, patients online, creates additional ethical challenges—and warnings. In a 2019 issue of Plastic and Reconstructive Surgery, three surgeon authors cite social media’s potential to benefit patient education within the context of the American Society of Plastic Surgeons (ASPS) Code of Ethics. However, they also discuss the temptation to misuse social media for business and economic gains.

“Surgeons may sensationalize their online presence to attract a broader audience, causing patients to fall prey to misinformation,” the authors indicate. The surgeon writers also perceive a “troublesome consequence of widespread social media use… [by an] increasing number of cosmetic surgeons not certified by the American Board of Plastic Surgery.” What’s more, they write, “This trend has serious safety implications for patients and impugns the reputation of board-certified plastic surgeons.”

A 2017 paper by Northwestern University researchers decry the “increasingly vulgar content [of posted patient videos] by a growing number of plastic surgeons that is not in the best interest[s] of the patient.” Some of these videos are more focused on marketing and entertainment than patient education, the researchers contend.

Ethical Decisions Are Not Always Clear-cut

Of course, making the right ethical decision is not always clear-cut. A good example is the 1990s case of twin girls—Amy and Angela Lakeberg—conjoined at the chest and sharing one abnormal heart and one liver. General and plastic surgeons and the babies’ neonatologist at Loyola University Medical Center in Maywood, Ill., declined to attempt separation surgery, despite parental wishes, since the operation would result in the death of one baby and offer few survival chances to the other.

But parental insistence—and autonomy—prevailed, and physicians at Children’s Hospital of Philadelphia, where other difficult conjoined separations had been performed in the past, opted to move forward with the operation. The result was the death of the weaker twin who was removed from the single heart and liver in surgery. The other, Angela, lingered in the hospital for nearly 10 months before ultimately dying.

In a later academic paper, now found in the digital library JSTOR, Loyola faculty posed these tough ethical questions, which our plastic and reconstructive surgery profession would do well to ponder:

  • Are there reasons, other than medical ones, for providing what experts would consider “futile therapy?”
  • Should parental and family autonomy—and values—supersede medical decision-making?
  • Would an ultimate decision not to separate the twins have constituted discrimination against the infants on the basis of physical handicap?
  • Should laws be developed allowing treatment to be withheld or withdrawn without parental consent?
  • Does failure to perform “futile therapy” violate the values of patients as human beings?

The Bottom Line

So, what is the bottom line for us as specialists and craftsmen in the plastic, aesthetic, and constructive surgery field? To quote the writers of the Ever-Important Role of Ethics in Plastic Surgery Today:

As tools, techniques, and interventions become increasingly powerful, plastic surgeons have the important responsibility to ensure that the treatments offered, education provided, and research performed are done so with a singular goal in mind: to improve the lives of patients.

How that is achieved is up to each one of us, adhering to the ASPS Code of Ethics and remaining true to the Hippocratic oath. Perhaps, neuroscientist and author Abhijit Naskar said it best: “A doctor [must] be a clown at heart, a scientist at brain, and a mother at conscience.”

Alexander Zuriarrain, MD, FACS, is a board-certified plastic surgeon and owner of Zuri Plastic Surgery in Miami. Listen to a podcast PSP did with him here.