The role of ethics in plastic surgery and medico-legal issues in plastic surgery

Introduction

Consideration of topics pertaining to ethics in the field of plastic and reconstructive surgery is frequently provocative. With ongoing clinical, technological, and interpersonal evolution, and the emphasis on innovation that drives this specialty, one may assume that new decision-making quagmires will constantly arise. This situation is only compounded by the novel ethical issues created by a specialty that is, for better or worse, often driven by advertising and commercialism. The connection of aesthetic plastic surgery to advertising has become even more complex in the age of the internet and social media. Somewhat ironically, despite the overwhelming ethical questions to be considered, the attention given to these issues within the plastic surgery literature is somewhat lacking. Presented here are some current areas of interest with an emphasis on the varied perspectives that may be brought to bear upon them. As authors, we will refrain from defining right and wrong, as subjectivity and differences of opinion are the sine qua non of ethical debates.

History of ethics and plastic surgery

The early ethical questions and concerns pertaining to the field of plastic surgery were largely religious rather than truly ethical in nature. Plastic surgeons were considered quacks rather than healers, and religious authorities voiced vociferous objections to cosmetic and even reconstructive procedures. Plastic surgery was thought to be used to hide the advanced stigmata of syphilis, and nasal mutilation that was sometimes inflicted as punishment. Across the board, religious authorities – Christian, Catholic, Jewish, and Muslim – expressed the concerns that plastic surgery involved interfering with divine creation. Church authorities excommunicated Gaspare Tagliacozzi (widely considered one of the fathers of our specialty) after his death and exhumed his body from the church cemetery, moving it to unconsecrated ground. Plastic surgery was further considered by Jewish authorities to fall under a prohibition of self-mutilation and was thought to be inherently feminine and therefore potentially prohibited to men. The field only gained true legitimacy during the two World Wars with the need for reconstructive procedures. However, as pointed out by the historian Elizabeth Haiken, the history of the specialty is forever colored by standards that could be thought to be frankly racist and anti-semitic. Aesthetic plastic surgery, to this day, often serves as a relief from the social anxieties created from living in a world with unrealistic beauty standards. Thus, from the very outset, that aspect of our specialty has presented unique ethical dilemmas that seem only to burgeon.

Core ethical principles and plastic surgery

The field of medical ethics in the US most commonly adheres to the moral theory of principlism, first described by Beauchamp and Childress in 1979. Within this framework, reasoning about ethical issues is based upon four moral principles: respect for autonomy, beneficence, nonmaleficence, and justice. Respect for autonomy describes a patient’s right to self-determination and self-governance and to accept or refuse care. Beneficence is the principle that one ought to do and promote good for the patient while preventing harm. Nonmaleficence dictates that a physician must not intentionally inflict harm on a patient. Distributive justice dictates that patients be treated similarly and fairly, with the result that benefits, risks, and costs are equally distributed among them. Plastic surgeons must carefully consider these principles when caring for patients.

These four core principles are not given equal attention in the plastic surgery literature. Respect for autonomy encompasses discussions of informed consent for procedures, photography, and marketing and has been shown to be the most fully explored ethics core principle within plastic surgery publications. The next most commonly publicized theme in plastic surgery is beneficence. Conversations of risks and benefits fall within the purview of both respect for autonomy and beneficence. Often related to beneficence is nonmaleficence, which is the third most common principle discussed. Distributive justice in plastic surgery is considered least often but still is an important ethical principle in the practice of medicine, particularly as diversity, equity, and inclusion initiatives proliferate.