Taxing Cosmetic Procedures by Physicians: Is That Ethically Just?
From the Washington Times and United Press International:"California State Board of Equalization is considering a proposal to levy a tax on Botox, the prescription medication used by many men and women to temporarily eliminate their character lines. ... The Texas Legislature is considering a bill that includes a 7.5-percent tax on elective cosmetic surgery, while Washington state legislators are thinking about a 6.5-percent tax on cosmetic procedures that would be used to pay for children's healthcare."
It is interesting that state legislatures are considering to tax the professional acts or skills of physicians who do cosmetic procedures. What are the legislatures saying about these procedures? Is it that cosmetic procedures are all luxuries and deserve to be taxed. Are these considerations ethically just? And what is next? What is it that physicians do which will be taxed next in the frantic races of states to balance their budgets? By the way, I doubt those in state government will tax what lawyers do professionally since lawyers probably make up a good proportion of the legislators themselves. ..Maurice.
posted by Maurice Bernstein, M.D. @ 9:01:00 PM
10 comments
10 Comments:
Dr. Bernstein,
I am a French law graduate, but I have also a complementary diploma in bioethics from the Catholic University of Louvain in Belgium.
By the way, I do also maintain a blog dedicated to human rights and bioethics (http://dawnofeurope.blogspot.com and http://aurore-europe.blogspot.com for the French version).
Much as I can understand your concern about taxation on medical acts, this initiative replies probably to a concern about:
1° Potential hazards to health from "luxury" cosmetic procedures (ought I to recall the damages caused by defective breast fillings?).
2° Desire for redistribution from a class of the population whose ethics and medical procedures may sometimes be questionnable (i.e. cosmetic surgeons).
As a representative from the legal art (you did single out my corporation), I might say that lawyers offer a service otherwise more essential to society than cosmetic surgeons... Hence taxation only for elective cosmetic procedures.
By the way, lawyers are also heavily taxed on their earnings, but they also know the law, and the ways to get around fiscal legislation...
I would rather ask you your opinion on the ethics of using Botox - a harmful poison - for cosmetic procedures. Is that not violating the first principle of bioethics, primum non nocere, since it is not truly reversible at will?
My compliments for your blog, well-informed and most interesting.
Marc Fernandes
Thanks for your comments, Marc. What concerns me about various legislative actions is the medicalization of things which shouldn't have anything to do with medical practice ( a gross example: use of physicians in the carrying out of legal executions, e.g.: determining mental capacity to appreciate the penalty, treating to improve capacity or at the end pronouncing the criminal's death) versus the demedicalization of strictly medical procedures such as those of a cosmetic nature (whether therapeutic/reconstructive or "luxury" ). ..Maurice.
Maurice -
I can't help but notice how you want to view cosmetic interventions as "strictly medical procedures," even going so far as to say "whether therapeutic/reconstructive or "luxury." Why divorce the "strictly medical" from the goals of medicine in this way? Isn't it much more natural to say that a procedure is medical or not depending on the purpose for which it is done? e.g., Amputating one's own digit as part of a mourning ritual, even if done by a qualified surgeon, strikes me as pretty far removed from medical practice.
Bob, I do consider interventions whether "therapeutic/reconstructive or luxury" as accepted medical practice procedures in our culture. Generally, there is the same degree of skill and the same degree of risks involved whatever the rationale was present for the procedure. The reason for the procedure should, therefore, not preclude that the procedure was medical if the procedure, such as "luxury" cosmetic surgery represents a legal and an accepted standard of medical practice (which apparently it does) . Chopping off a finger by a physician for a cultural reason and attending to the subsequent wound is still medical even though the basis for the procedure may not represent a medically professional standard of practice in other cultures. On the other hand, in our U.S. culture, participating in a criminal execution is not an acceptable activity of a physician and therefore whatever the acts of the physician are in this regard, are something else but not medical and shouldn't be considered as such. Currently, a physician participating in active euthanasia in the U.S. is not a medical activity.
I suppose what I am saying is that identifying whether something is medical or not should be determined by the culturally accepted standards of medical practice and not necessarily other factors. Bob, if the "goals of medicine" are measured by what is considered standards of medical practice where it is practiced, then you and I are saying the same thing. ..Maurice.
Maurice -
I'm sure it was not your intent, but I find your remarks "chilling." To wit: "if the "goals of medicine" are measured by what is considered standards of medical practice where it is practiced..." then the nazi doctors were, after all, pursuing the goals of medicine. That would seem to make all the talk about the nazi "perversion" of medicine just a lot of rhetoric reflecting nothing more than who happened to win the war du jour. I much prefer the notion that the goal of medicine is the promotion and maintenance of health (or the prevention and amelioration of disease).
Bob, “touché”--of course you made an excellent point. Maybe I have to provide some universal standards which trump the additional cultural ones—such as what you have already suggested “the promotion and maintenance of health (or the prevention and amelioration of disease).” But the “health” could be interpreted also as psychologic or emotional health. “Luxury” cosmetic surgery could be supported by the latter interpretation. Finally, I am sure that the Nazi doctors felt that their treatments and experiments were at the least promoting the “health” of the German race including the German military. ..Maurice.
I have no problem acknowledging the biopsychosocial nature of health. But I also subscribe to the allopathic view of medicine, according to which interventions are directed to the removal (or at least the reduction) of the dysfunctional condition. From that perspective, morbid psychological distress probably needs the help of psychotherapy, or perhaps psychopharmacological therapy. Cosmetic surgery regularly treats a disordered psychology as normative, and simply changes the body to remove the stimulus that caused the psychological disorder to become manifest. Following "successful" surgery, the disordered mind is still there, only the conditions for its manifestation have been removed. That's not allopathy.
As for the promotion of "population health," that's the domain of public health rather than medicine, which is directed to the health of the individual patient, i.e., the person directly affected by the interventions in question.
Dr. Bernstein,
Maybe that you ought to distinguish the nature of the acts. Firstly, assisting in an execution runs counter to the Oath of Hippocrat - in addition, I doubt that a physician present in an execution chamber is there in a therapeutic quality.
Your examples spoke of the forensic aspect of medical practice. That has also little to do with medicine, if not that the physician is required to use his art to come to a legal conclusion. And by the way, appreciating the mental capacity of someone is a legal action, though the ultimate responsibility of saying whether one is fit or not to understand legal proceedings belongs to a judge.
I have worked precisely on that division between the forensic role and the therapeutic role, and most of the scientific litterature in that field separate both roles and recommend that they do not be carried out by the same person. In Europe, the current practice in police custody is generally a confusion of these two roles (forensic and therapeutic) because of a lack of physicians (and of the cost).
Finally judging if someone may be involuntarily committed is an example which is not present in your comment, but it belongs to another field: that of the psychiatric responsibility of the physician who then acts at the same time as agent of the patient, and agent of the society.
As I have posted on earlier topics, I really feel it is improper for any physician to wear "two hats". That means that any physician who treats and cares for individual patients should also NOT be something else including forensics. A person with an M.D. degree can certainly do work in forensics but must never be in any capacity as a treating physician. That is because the focus of the treating physician's acts is only to promote beneficence of the individual being attended. If the physician also wears another hat, there may be others and other interests to be respected. ..Maurice.
It is wrong to think that only rich do cosmetic procedures. From what I heard, many lower middle class women save money and do it as well. So it can hardly be considered tax for the rich.
It is also a well-known fact that good looking and younger people have better chance of finding a job than plain and older people. This applies to virtually every profession, not just models and actors. A 45-year old secretary, even a 45-50 year old engineer has a harder time finding a job than a 30 year old. It is illegal to ask for someone age at an interview, so often the decision is made based on looks.
So, until the mindset changes and looks and age don't enter into employment decision (in reality and not just in a law book) except when it is relevant for the job, cosmetic procedures shall not be considered luxury.
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