Bioethics Discussion Blog: Human Enhancement in the Healthy:A Role for Physicians?

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Wednesday, March 29, 2006

Human Enhancement in the Healthy:A Role for Physicians?

Continuing with the topic of human enhancement, I had a topic on my now inactive "Bioethics Discussion Pages" on whether there was a role for physicians to prescribe or perform procedures for strictly cosmetic reasons: in order to improve the patient's appearance and performance in the absence of disease or deformities from birth or injury or illness? Here are my visitors responses 2000 to 2004, with the oldest at the bottom of the post. As I noted in the comments section to the last post, I am not in favor of such human enhancement by physicians and therefore I would not be in favor of human enhancement of brain or body with nanotechnology in which physicians would be involved. ..Maurice.




Is a Role of Physicians to Prescribe or Perform Procedures for Cosmetic Reasons in the Healthy?

There are questions raised whether everything physicians do or are requested to do are part of their role which society has given them through the ages. There have been questions, for example, whether physicians should participate in legal executions. Tylor Kase, in his posting below, raises the issue of prescription of anabolic drugs to improve performance.

The concern expressed by Tyler raises a more general issue and that is whether physicians are responsible to not only prevent and treat disease but also to make patients look and feel more attractive and powerful. Prescriptions for anabolic steroids as Tyler noted have potential hazards but also there are hazards related to, for example, cosmetic surgery.

On Friday February 11, 2000 Tyler Kase ( lil_g_ride@hotmail.com) wrote:

"My position on Anabolic steroids is that I don't think it should be used only by doctor's through the means of rehabilitating patients who have weak ligament, joints, and tendons. It shouldn't be used by any kind of athlete to help them to become better at sports and to make them more muscular. After doing a little research on this topic I learned some of the side effects that comes with these steroids such as hair loss, massive amounts of acne on the body, and men developing breast. I think everyone should be informed on these side effects. I'm sure people know what they are. I just don't understand why people still use the steroids. This is not a kinda of drug you want to abuse. People should think before they ruin their lives.

Thanks alot,

Tyler Kase"

Here is the question:
Do you think it is right for the role of a physician to include writing prescriptions or carrying out procedures in order to improve the patient's appearance and performance in the absence of disease or deformities from birth or injury or illness?


---- THE DISCUSSIONS ----
Date: Thu, May 6, 2004 12:11 PM From: khmaio@earthlink.net To: DoktorMo@aol.com

Do you think it is right for the role of a physician to include writing prescriptions or carrying out procedures in order to improve the patient's appearance and performance------------------------------( in the absence of disease or deformities from birth or injury or illness)?

The issue that comes to mind ( I would end the sentence above earlier) is administering drugs so that a person can appear competent to take part in a trial. The "cosmetic" reason, an appearance to present a false reality, is in direct conflict with ethics, a blurring of line betwen medical ethics and trial ethics.

The drugs are forced by law. Should they also be forced by medicine is the dilemma.
Harold A. Maio


Date: Wed, Apr 2, 2003 4:48 PM From: joquina@hotmail.com To: DoktorMo@aol.com
It all depends on what type of surgery it is.I do not see anything wrong for a woman who want larger breast if they are a size A or B cup.I do see something wrong for a small frame woman to want a size D cup. I do not see anything wrong with having a tummy tuck done for someone who lost a substantial amount of weight; but still have excess skin.I do believe that some of the cosmetic surgeries being performed today are not necessary. Society is so big on looks and the shape of their body; plastic surgeons see it as away to make money by doing these outrageous procedures.


Date: Mon, Nov 11, 2002 8:39 AM From: elizabethalecrone@hotmail.com To: DoktorMo@aol.com
DoktorMo@aol.com My name is Elizabeth LeCrone, I am a Philosophy major at the University of Oklahoma, a healthcare worker for over twenty years and the wife of a physician. My interest in the field of medical ethics has increased over the past ten years because of the changes in the healthcare delivery systems and the new technology introduced in the past decade. The responsibility of a physician is to treat each patient to the best of his ability, to inform patients of possible side effects of any procedure or medication and to also safe guard the mental health and welfare of his patient. When you deal with the physical enhancement of a person you deal not only with the physical appearance of that person but also their feelings about their own identity and self-perception. Our culture dictates that everyone should be young and thin and beautiful and those who do not meet that criteria often suffer. A physician who is a skilled reconstructive surgeon can take years off of a persons appearance. Unfortunately, there are many less than ethical doctors and dentists who have jumped on the bandwagon to do skin-peels, botox injections, colagen injections, etc. just because these are seemingly simple yet lucrative procedures. Sometimes they are not skilled or trained to give the results that should be expected. The sad commentary for our society is the fact that as humans we have become conditioned and compelled to be more than what nature made us to be. For a child who is ridiculed by a nose that is a little to big or ears that stick out too far, most often, time is the best cure. Any mother who would consent to allowing her sixteen year old daughter to have breast augmentation is sending a very wrong message to her daughter. Our society is so caught up with sex appeal, that every twelve year old girl wants to be Brittney Spears. The idea of reducing young girls to sexual objects before puberty is just wrong. All enhancing surgeries are not successful. Many times the expectations of the patient go far beyond the ability of the surgeon, no matter how skillful. Many times, the psychological need of the patient is what needs to be addressed, not their bodies. It is my opinion, that to constantly be searching for artificial means to satisfy our egos and failing to accept ourselves as human beings, we lose sight of the importance of our individuality. Women more than men have struggled with unrealistic role-models. The media and advertising depends on the fact that we will never be satisfied with who we are and how we look. I am more than my appearance. I have tried to instill in my daughters their own sense of identity and self-worth. Medical advances have made it possible for anyone to do procedures that are cosmetic in nature. There are dentists who have gotten into the botox business because it is lucrative. There are plenty of OB-Gyn physicians who have turned their practices away from the delivery of babies to tummy-tucks and breast augmentation. This is a sad commentary of modern medicine. There will always be those in the profession who look more to the money than to the welfare of their patients. A physician who truly has the well-being of his patient in mind will not be doing procedures on his patients that he is not board certified to perform and most good reconstructive surgeons will look at the psychological motivation and seek counseling for that patient prior to any radical changes. Plastic surgery becomes an obsession to many who can afford it. It is the health care provider who must look beyond the revenue generated from the procedure and help his patient make a wise and prudent choice before electing surgery. Until we change the perception of a society who values Jennifer Lopez and any professional sports personality over the great minds of our world we will deal with unscrupulous physicians who seek to make a buck off those who are so shallow that beauty can only be "skin deep".

Date: Sun, Apr 27, 2002 8:21 AM From: paralogik@optushome.com.au To: DoktorMo@aol.com
It seems that it would be inappropriate to legally preclude treatment for non-pathological and non-medical conditions (I am very thankful for having had braces as a kid). western societies are built upon ideals of personal choice and freedom, and preventing people from pursuing their own aesthetic projects does violate this. however, being unwilling to completely proscribe against cosmetic surgery/prescriptions does not mean that we should fail to critique them when the social structure that such practices arise within and sustain can be extremely damaging, both psychologically and physically. the first problem i would like to suggest with the 'individual choice and freedom' defense is this: that it seems distinctly naive to claim that the motivations of people to get breast enlargements or liposuction or face-lifts arise from purely autonomous motivations. such desires arise within a social context which valorises certain physically ideals and stigmatises others. this is problematic. furthermore, our focus on appearance as something to be assessed, corrected, worked upon and subjected to judgement can lead to a real shallow materialism in our dealings with others and interpersonal relations. in such a context, can the desire to have surgery to correct the deformity of small breasts really be considered autonomous? secondly, I am interested in the extent to which aesthetic modification, in that it can involve surgery, can lead to the medicalisation of certain traits previously considered normal, i.e. the pathologisation of more and more features which we generally just live with. for example, the American Society of Reconstructive and Plastic Surgeons stated in an official comment to the FDA that small breasts are not only a deformity but a disease, which leads to increased levels of depression associated with poor self-image. surely this begs the question of whether it is the disease of small breasts which leads to poor self esteem, or the social construction of small-breastedness as disease and pathology requiring corrective surgery?! maybe what is required is not medical intervention to correct those features we consider aesthetically unacceptable, but a less shallow way of dealing with issues of beauty and self-esteem. all this may seem tangential to the issue of whether cosmetic surgery should be permissible. i do not believe that it should be prohibited, but I think that we should be very critical of it, and particularly when it is linked in with a capitalist system in which people's sense of self is exploited and manipulated in order to make money for cosmetic surgeons.
Date: Mon, Feb 4, 2002 10:36 AM From: joe_palmer@att.net To: DoktorMo@aol.com

Yes, I think a valid and legitimate role is for the physician to assist in improvement of a patients appearance and/or wellbeing even in the absence of disease. So much of our psychic health comes from our actual image as well as the mental self image we have. If appearance were not important, the cosmetic industry would not exist. The ability to enhance one's appearance should be encouraged and promoted. Joel Palmer


Date: Tue, Aug 7, 2001 4:43 PM From: dmacdoug@usc.edu To: DoktorMo@aol.com
This question opens up a very large area of physicians roles. Traditionally the physician has held a certain role in society. But in modern society that role is and has been changing for many reasons one of which is the law. Under US law and those also of many other countries, over the last century or so, physicians have gained a legal status that they didn't formerly have. They have been given the almost exclusive legal right to prescribe drugs and to perform surgery. This changes the physicians ethical responsibilities somewhat, for under this legal franchise, it means that if the physician, for moral, ethical, financial or other reasons, refuses to perform these tasks, he is, in practice denying those who would like to have these things performed, the right to do so. It would seem as though, the physician would have to choose either to reliquish the exclusive right to perform these tasks, or alternatively, accept the responsibility to do so. It wouldn't seem as though he could ethically take the position that I only can do this and then refuse to do so. It would not be the physicians role to make this choice, unilaterally on behalf of society.

Donald MacDougall dmacdoug@usc.edu
Date: Thu, Jan 4, 2001 11:28 AM From: aj_16_16@hotmail.com To: DoktorMo@aol.com
I think if the people want to pay for the doctor to make them look better or something, that is their business. I also think if the procedure is not going to harm anyone else, then the doctor should follow through with the patients orders.


Date: Wed, Dec 6, 2000 4:05 PM From: slicks@home.com To: DoktorMo@aol.com
Hi, I firmly believe in reconstructive and cosmetic surgery! I work for one of the most well respected plastic surgeons. I have seen him work wonders for patients. There are to many people out there who obviously have to much time on their hands, to be so opinionated about such a thing. Everyone is an individual and it should be their personal choice. It's about what makes them feel good, not what everyone else thinks. Anyone doctor can call himself a plastic surgeon but believe me it is not learned it is a true talent.


Date: Sun, Nov 5, 2000 5:47 PM From: keileym@hotmail.com To: DoktorMo@aol.com
what about liposuction? what if a only slightly overweight person wants liposuction? should it be provided even if the risks outweigh the benefits?


Date: Tue, May 16, 2000 10:32 AM From: af485@lafn.org To: DoktorMo@aol.com
Phisicians should definitely provide cosmetic care to patients, but always under the auspices of "primum non nocere". We are responsible not only to the patient's physical but also his psychic health. When a person's body image is defective, it is the physician's responsibility to help alleviate the psychic pain. Help might be in the form of counseling, psychotherapy, medications or plastic surgery or a combination of these. Of course whatever course is chosen, the same mandates apply as in any other treatment. Is the patient's request rational in view of what is requested? Does the physician agree that the treatment the patient wishes is the best in his opinion also? (If not, explanation of his reasoning against the treatment and, if the patient still wishes referral, this should be done by recommending the best physician for th the requested course of treatment). Does the benefit of the treatment significantly exceed the risk? This point is far more essential in cosmetic therapy than in the treatment of illness or disability. The physician might include a mental risk profile with a necessity scale from 1 to 10: 10) being a disabling or disfiguring congenital defect, 1) a recommendation by a family member or friend(?) that the patient's appearance might be improved by plastic surgery.Hans


Date: Wed, Mar 29, 2000 7:37 AM From: SBERKOWI@AspenMed.org To: DoktorMo@aol.com
Braces, acne, contacts - these are all types of treatements that are recommended to improve appearance and are generally accepted. Braces may often be recommended to simply straighten one's teeth without any space problem. Acne could be considered a normal developmental state, yet we treat it to improve appearance and prevent disfigurement. Contacts are often requested by patients so that they can get rid of their glasses and/or to improve their appearance. I site these examples to show that a universal ban on helping patients for cosmetic reasons is not appropriate, while a thoughtful approach to the use of any treatment that is primarily designed to improve appearance, such as growth hormone treatment for "normal" short stature (non-GH deficiency) or steroids to increase mass, is indicated. As with all treatments, balancing the potential benefits of the treatment against the risks of both the treatment itself as well as non-treatment of the "condition" is a worthwhile way to proceed. - Sheldon Berkowitz, MD

9 Comments:

At Wednesday, March 29, 2006 5:22:00 PM, Anonymous Moof said...

My own personal opinion about cosmetic surgery for the sake of superficial beauty, when no deformities or medical reasons are extant, is that the seekers would probably be better off with counseling in order to learn to accept themselves in an emotionally and psychologically healthy way.

However, there are those who want cosmetic surgery, and there are physicians who are willing to spend their time humoring them ... I would never interfere with them.

Some of those who have these surgeries really do have an aesthetic problem which goes beyond their mere imagination ... and there are others who are just silly ... but who's going to draw the line? And where will it be drawn?

One commentor mentioned that she thought a breast enlargement was fine if the woman had a size A or B cup, but that a small person going for a D cup would be wrong. Why? Who would suffer (besides herself) for her choices? Who would she be hurting? And who would be the one to decide " ... a C cup and no larger for you!"

Yes, I think that some of these procedures demean medicine, and turn perfectly attractive people into side shows ... but we have to question if they're inherently wrong, and if we have the right to regulate or even forbid the procedures.

Dr. Bernstein - how do you view your fellow physicians who spend their medical vocations doing nose and breast jobs?

Where do you draw the line between theraputic reconstructive surgery for a valid genetic deformity, (even if it's not a gross deformity, like cleft palate) and people like Michael Jackson, who've had so many surgeries that they're disfigured?

 
At Thursday, March 30, 2006 6:52:00 AM, Anonymous Bob Koepp said...

Maurice -
Like you, I don't think cosmetic procedures, or any procedures not directed toward improving a patient's health status, should be viewed as a "proper part" of medicine. But I don't think that means physicians should not be involved in the provision of such services. I don't think I want anybody other than a trained surgeon performing complicated cosmetic procedures.

For me, this is closely analogous to the place of abortion in medicine. I think that relatively few abortions are actually "medically indicated" -- the rest being analogous to cosemetic procedures. But there was good reason to "medicalize" abortion services a couple generations ago, because of the inherent medical risks of the most common procedures (i.e., D&C). With the advent of abortifacients that can be safely administered by women themselves, however, I think this rational for physician involvement would more or less evaporate, and it would be time to de-medicalize abortion.

Similarly, if the technologies and techniques of cosmetic enhancement evolve in a way that would safely permit demedicalization, then it might make sense to say physicians should not be involved.

 
At Thursday, March 30, 2006 9:07:00 PM, Blogger Maurice Bernstein, M.D. said...

Bob, I would agree with your analysis. I presume however that you would find no merit in physicians providing anabolic steroid prescriptions for muscular strength enhancement. Moof, with regard to how I look at physicians who do breast and nose enhancement, since these are not illegal procedures, I concur with Bob Keopp's argument that physicians are the only ones who can legally perform the operations and provide a safe and potentially satifactory outcome. ..Maurice.

 
At Friday, March 31, 2006 10:55:00 AM, Anonymous Bob Koepp said...

Yes, I think we are in agreement here. Even though I think there can be good reasons for physicians to be involved in the provision of services that don't promote the traditional goals of medicine (i.e., promoting health), I do think a line needs to be drawn where the Hippocratic author drew it, i.e., "First do no harm." From what I've read, the medical risks associated with "steroidal body building" would put this out of bounds for any conscientious physician.

 
At Thursday, May 18, 2006 10:20:00 AM, Anonymous Lindsay said...

What about providing cosmetic procedures to a patient who does not request the procedure? Should a 16 year old's mother request that she be given breast augmentation? What if the girl has not been consulted or would prefer not to undergo the procedure?

Should a mentally disabled patient be given a rhinoplasty at the request of his care providers? At what point is the cosmetic defect considered 'bad' enough that the guardian can decide for the patient w/o the patient's understanding and /or consent?

 
At Thursday, May 18, 2006 11:29:00 AM, Blogger Maurice Bernstein, M.D. said...

Lindsay,there is no doubt that decisions of physicians to perform cosmetic procedures which are not related to trauma or disease or congenital deformity on children or those mentally disabled is an additional complication to the decision whether to perform the procedure at all. First one has to decide whether subjecting the individual to the risks of surgery is appropriate for the potential benefit to be gained. Often the benefit is related to the better quality of life which the procedure could provide. This quality of life is something that the subject should decide upon since the physicians or guardians can only guess based on their own experiences in life. The subject may not be able at the time to evaluate the benefit, if any, to the quality of life. If the patient can explain a decision in this regard and has the capacity to weigh the benefits vs the risks (and some children or mentally disabled may be able to do that) then the decision of the patient should be considered. I think it is wrong for the surgeon to operate simply on the orders of the guardian for this kind of surgery. The problem is with "mother knows best" is whether the decision by the guardian is being made mainly for the benefit (psychologic comfort) of the guardian in these non-medically related cosmetic issues. ..Maurice.

 
At Thursday, May 18, 2006 9:14:00 PM, Anonymous Lindsay said...

Thank you, Maurice.

I am new to this arena of debating bioethics. So I don't know the answer to what may be a simple question to you: What does a physician do who believes a cosmetic procedure to be performed on an unconsenting minor is mainly being requested for the psychologic comfort of the guardian? Who decides what is non-medically related? And if the physician refuses to perform the surgery, will the guardian simply find another surgeon? So to make sure it's done properly and safely, should the conflicted surgeon go ahead and perform a cosmetic surgery on a minor child for the benefit of the guardian? Can a court order such a surgery to take place against the wishes of a young child (less than 10 years of age, for example)?

 
At Friday, May 19, 2006 4:54:00 PM, Blogger Maurice Bernstein, M.D. said...

Plastic surgeons are not machines or technicians, they are physicians. As such it is their duty to weigh all the facts available and decide whether the surgery would be appropriate. They don't simply do the surgery because they are asked. (Some or many might, but they have to live with their decision.) Therefore, it is the surgeon who has the medical training to know whether the requested cosmetic change would be non-medically related. If a surgeon suspects that the motivation for the surgery is not primarily for the best interest of the patient, then the surgeon has the moral and legal right to refuse and refer the family to other surgeons who may make a different evaluation. I suspect a court can just about order anything but whether the court would order any surgeon to perform surgery that the surgeon felt was not appropriate, particularly cosmetic surgery, would be very, very doubtful. ..Maurice.

 
At Monday, May 22, 2006 12:21:00 PM, Anonymous Lindsay said...

So why do American physicians perform routine infant circumcision in the face of the AAP's 'not medically necessary' stance and much data and practical evidence from non-circumcising nations that circumcision is not medically necessary (Japan, Finland, UK, etc)?
How do American physicians ethically justify amputation of healthy, normal tissue on a non-consenting individual for the cosmetic preferences of the guardian?
I appreciate that you've spent time discussing this with me, many physicians choose not to go consider the bioethics of cosmetic surgery at all, and really try to avoid the topic of cosmetic surgery on minors.

 

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