Controversial business practices and ethical implications

Plastic Surgery

Teen Plastic Surgery: A Controversial Medical Practice

According to the American Society of Plastic Surgeons, in 2007, more than 87,000 teenagers had cosmetic surgery; and that number has grown exponentially since. Although aesthetic cosmetic surgery is popular amongst United States teens, physicians and plastic surgeons worry that such invasive surgery on teens' still growing bodies can be dangerous. Other developed countries, including Germany and Australia, are considering banning all but medically necessary plastic surgery for anyone under the age of 18. However, the question remains, if such a measure were taken like that in the United States for minors stem the tide of teenagers going under the knife? This paper will address the controversy associated with teenagers and aesthetic cosmetic surgery in the United States, and the business of plastic surgery for teens, from a legal, ethical, and social responsibility standpoint.

Introduction

In a country, and dare say a world where image is everything, it's not uncommon for adults, and particularly those in the public eye, to elect cosmetic surgery to meet the expectations of a demanding society that perpetuates the importance of physical image (Ali & Lam, 2008). But what about teenagers? Each year thousands of teenagers elect to have plastic surgery. In the past, when an adolescent had plastic surgery, it was most often to correct birth defects such as cleft palates, for example, or to reconstruct after serious injury.

In most recent history, however, more and more adolescents are seeking and receiving elective plastic surgery. In 2003, more than 223,000 cosmetic procedures were performed on patients under the age of 18. More than 39,000 were surgical procedures such as nose reshaping, breast augmentation, liposuction, breast lifts and tummy tucks (ASAPS, 2003). But are there more than simple aesthetic reasons for a teenager to want plastic surgery? And as the consideration is made regarding adolescents and plastic surgery, there must be some thought given to under what circumstances plastic surgery is appropriate for teens.

Monica had always been very self-conscious about her nose. For as long as she could remember, she wouldn't leave the house without applying make up that would make her nose appear smaller and more narrow. During her high school years, to draw the focus away from her nose, Monica admits to wearing padded bras and shirts with her stomach exposed. However, after her fellow classmates began to post derogatory comments about her on Facebook, Monica made the decision to make a permanent change to her nose. She met with a counselor to determine if she was emotionally prepared for her decision. Monica had rhinoplasty at 15. Now she maintains that she is more comfortable with her appearance, and is more happy and confident.

Jacob, in elementary school, was frequently called "Dumbo" because of his ears. He maintains that he would just turn away to avoid fighting. In the 6th grade, Jacob began to grow his hair out that conveniently covered his ears, and in his own words, "kept him out of trouble." Jacob wanted to join a youth fire service program, but learned that short hair was a prerequisite. He was reluctant to cut his hair and didn't join the organization he had been so very excited about. Jacob realized that how he felt about his ears was detrimental to his life and lifestyle.

His mother was supportive of his decision to have elective plastic surgery. Today, Jacob is pursuing a fire science degree.

Teens like many adults, expect that plastic surgery will garner greater self-confidence, but does it? At present, there are no empirical studies that examine the long-term benefits amongst adolescents who have undergone elective plastic surgery. Current research indicates that patients who receive breast augmentation are four times as likely to commit suicide compared to other plastic surgery patients (Brinton, 2001); which raises significant questions about the mental and emotional health of women who choose implants and the psychological benefits of the surgery. For many, liposuction is an elective surgery that presents specific concerns because of its association with eating disorders (Rauste-von, 1989). Moreover, there is a concern regarding any form of aesthetic surgery and Body Dysmorphic Disorder (BDD); defined as "preoccupation with an imagined or slight defect in appearance that leads to significant impairment in functioning"; particularly when the average onset of BDD is 16 years of age. The difficulty, however, likes in the fact that since the goal of cosmetic surgery is to transform and improve appearance, there may be difficulty in distinguishing between desire and pathological preoccupation (Thompson, 2001).

"Surgery during the teenage years should be performed only to correct impairments and traumatic injury," says Dr. Asha Manaktala, a pediatrician in Connecticut. Dr. Manaktala iterates the sentiments of a number of health professionals, parents, and people in general. However, the Federal Drug Administration approved saline breast implants for women under the age of 18 more than a decade ago (FDA, 2000). It is legal for a plastic surgeon to perform for anyone under the age of 18 as an "off label" use; and between 2002 and 2003 the numbers of adolescents having this kind of surgery tripled.

The American Society of Plastic Surgeons did not take an official position regarding breast augmentation for patients under 18 until December 2004; at which time, the organization collectively expressed that they were against it (ASAPS, 2005).

The long-term emotional, physical and economic implications of the most popular plastic surgeries, including liposuction and implants are unknown. Despite the documented risks of these elective surgical procedures, the general public seems to have an inflated sense of the benefits with a minimized sense of the risks of plastic surgery (Thompson, 2001).

Another consideration that must be made when considering the issue of teens and plastic surgery is the role of the surgeon himself. Will most plastic surgeons make an objective and accurate judgment about whether an adolescent is an appropriate candidate for plastic surgery? Furthermore, if plastic surgeons are performing surgeries that many psychologists and physicians would question, is there some obligation on the part of medical societies and ethicists to provide more guidance than is currently being provided by the very organizations that benefit the most financially from plastic surgery's being performed? The purpose of this paper is to analyze the issue of teen plastic surgery through the contextual and value-based framework of law, ethics, and social responsibility.

Legal

Where does the law come into play when considering the issue of adolescent cosmetic surgery? Who has the ability to make the ultimate decision? Is it the adolescent, the parent(s), the courts; or is there any clear legal instruction with regard to this issue?

Newman, in his article, "Adolescent Consent to Routine Medical and Surgical Treatment: A Proposal to Simplify the Law of Teenage Medical Decision-Making" argues that there has been substantial in congruence in the law regarding adolescents and their right to give legitimate and valid consent for routine medical procedures. An adolescent can be emancipated by a judge, based on no personal knowledge of the teen, but information provided third party and suddenly have the capacity to make medical decision; but in other circumstances with an adolescent of the same age, no such decision making power exists (p. 502). Newman argues further that juveniles, more and more, are treated as adults by the criminal justice system; however, juveniles of the same age with no criminal involvement cannot make the decision as to what will happen with their bodies; particularly when ill or injured (Holmes, 1989).

Newman posits that a deontological rule in the Kantian mode should be adopted with regard to this issue; suggesting that all minors over the age of 16 should have the opportunity and right to make their own independent choices and decisions as to what should be done to and with their bodies. Newman maintains that he favors this approach with specific regard to routine medical (non-life threatening as determined by a physician), and surgical treatment (p. 504).

The recognition of children's rights in the United States can be attributed to the Supreme Court case of In re Gault in the 1960's, wherein the court upheld the decision that "the right to freedom from physical confinement was held applicable to children" (Teitelbaum, 1999). This, Newman argues, began the recognition of children's rights being protected. As there is no categorical requirement for parental consent with regard to a minor using contraception or abortion, there still exists "the greater authority to regulate decisions and conduct of minors which does not entail assumptions about equal capacity" (Zailkind, 1996).

Susan Hawkins point out in her comprehensive law review article regarding the rights of competent minors in litigated medical treatment disputes, that there is a disconnection between the staunchly held beliefs in the United States when it comes to the parents' incomparable authority to make their children's medical decisions and the continually evolving notion of autonomy for all competent humans, including those under the age of 18 (p.2076).

Michele Oberman, in her article, "Minor Rights and Wrongs," makes the distinction between a competent, emancipated and the contemporary version of the "mature minor." She purports that "the laws governing minors in the health care setting have evolved more or less in accordance with societal perceptions of adolescents' health care needs" (p.356). Further, Oberman posits that maturity is more or less code, allowing minors to consent to their own medical treatment in situations were society deems it appropriate; and at the same time denies minors' access if there is a possibility of long-term adverse consequences (p. 358). She describes this as a form of utilitarianism which governs minors' access to health care. If minors are allowed to make medical decisions that exceed what society renders as appropriate from the viewpoint of utility, then there must be a clearer and more scientific view of the nature of adolescent capacity (Newman, 2001).

There has been no clear cut standard established or adopted by the court as to what constitutes a mature minor, capable of making their own medical decisions. Newman argues the reason there is no precise standard articulated is because the determination to increase minors' rights in the medical area has not been so much about the belief that the adolescent was mature, but rather a determination made by society to prevent unwanted consequences for the community at large (p.512).

Statutes for mature minors are not uncommon, and can be found in jurisdictions all over the United States; permitting under-age adolescents the right to consent to certain medical issues, such as substance abuse, mental illness, pregnancy, contraception, and sexually transmitted diseases (Tietelbaum, 1999). Newman argues that seemingly, there both the adolescents and society benefit from these mature minor statutes; and as long as both are served by their existence, minors will continue to receive access to medical treatment. Moreover, because minors' are frequently unable to discuss these kinds of medical issues with their parents or guardians, and society benefits from fewer teens engaged in illicit substance abuse, fewer unwanted pregnancies, fewer sexually transmitted diseases, the statutes will more than likely remain in place.

In states where there is an absence of mature minor statutes, there is frequently mature minor doctrine (Newman, 1999). Mature minor doctrine is common law doctrine that permits minors who are able to comprehend the nature and consequences of the medical treatment that is offered are then able to give valid consent for treatment.

As evidenced by the aforementioned, the issue of legality and minors' access and consent to medical treatment can be a slippery slope. There is no general consensus regarding the classification of adolescents, when their rights begin, and when a parents' rights end. There are no clear and consistent guidelines as to when a minor under the age of 18 can be the decision maker in medical decisions. If there are multiple definitions as to what and adolescent is and when they are eligible, or even capable of making their own decisions regarding medical treatment, and inconsistency as to how these definitions are applied, the issue becomes much more controversial and confounded when it comes to adolescents and their right to consent to medical treatment.

Ethics

Ethics as a branch of philosophy is not a new concept. Some argue that it began over 2400 years ago with Socrates, and was one of the central interests of both Aristotle and Plato. This development represented a relatively significant break from what previously existed. Before Socrates, ethics was almost invariably associated with religion and religiosity; with moral rules regarded as laws passed down by a deity, with a prevailing sense of right and wrong as a matter of divine prohibition and injunction. The notion that moral truths can be derived through a process or rationale and thought challenged the views that moral truth must originate from a deity, and in doing so, raised very important and controversial issues (Jenkins, 2007).

British philosopher, Jeremy Bentham (1748-1832) developed the systematic theory of moral philosophy referred to as utilitarianism, and the theory was further refined and elaborated on by his principle disciple, John Stuart Mill. Utilitarianism is said to have grown out of Bentham's dissatisfaction with the British legal system. Bentham and his followers are said to have regarded utilitarianism as more than just a moral philosophy but as a theory of social reform, an objective, as well as a scientific system of ethics (Cavico & Mujtaba, 2005). Bentham posited a nascent principle of ethics that was universal in nature and provided a mathematically calculable empirical way to evaluate the standard for morality (p.99).

For utilitarian's, morality's focus was on the consequences of the actions. In and of themselves, actions are neither good nor bad; rather, they are judged solely based on the virtue of their consequences. After a utilitarian identifies the action according to an ethical evaluation, he then makes a determination about the people that are directly and indirectly affected by said action.

Then an attempt is made to determine the consequences of the action, whether good or bad concerning those affected. Then it is incumbent upon the utilitarian to attempt to weigh and measure the consequences. If good outweighs bad, then the action is considered moral. Conversely, if the bad outweighs the good, then the action is considered immoral (p.101).

Another important component to Bentham's theory is that everyone is utilitarianism is treated as equals; with none more important that another. Every persons, pleasure, pain, and happiness registers the same value; with none registering more significantly that anyone else's. Calculations used to measure are impersonal. What serves to complicate the utilitarian model is the fact that it is based on consequences that cannot be truly foreseen, reasonably measured, or predicted with any certainty. A number of contingencies impact consequences, with the majority of the results being uncertain. As such, consequences can never fully be foreseeable (103). Moreover, act utilitarianism evaluates each individual, and the particulars of that individual in a particular circumstance. There is no globalization of an action in a circumstance rendering a global evaluation of right or wrong.

Further assumptions made by utilitarianism are that quantities of pleasure and pain generated by said action can be measured on a numerical scale. Mathematically, the quantity of pain is subtracted from the quantity of pleasure and the determination is made whether the action is more painful or more pleasurable. The greatest total good is then determined with regard to the action (p. 105). What has proven problematic and increasingly controversial about utilitarianism is how the numerical measuring is completed as the practicality of application presents ethical concerns.

However, even with utilitarianism being considered a controversial theory of moral philosophy, some would argue that there is still benefit to the use of it in making moral determinations. Weighing consequences of an action before the action is taken can be of great benefit to the person when trying to make decisions. Cavico and Mujtaba posit that a person who focuses on the consequences of their actions is primarily concerned with personal impact. However, utilitarianism requires the person to consider the societal impact and consider the consequences of their actions as it relates to others (109).

For any business, the goal is to be profitable and money is considered the "good" in the good vs. bad moral equation. Most frequently, a cost benefit analysis is used to determine the consequences; and this system in and of itself is a form of "utility calculation" (p. 112). When considering teens and plastic surgery through a utilitarian lens to determine the moral rightness or wrongness of an action, there are a few significant actions to consider.

The first to be considered is the action of the plastic surgeon. Is it moral for a plastic surgeon to perform an aesthetic operation on a teenager? The stakeholders involved in this action and therefore the surgeons' decision includes all those who stand to benefit financially from the surgeons decision to operate. The question is not nearly as difficult to make, for some, when reconstructive surgery is considered, but in this case, the surgery under consideration is purely cosmetic. Possible stakeholders may include the patients' primary physician if consulted, and/or a counselor if engaged, to make recommendations regarding the adolescents' readiness for surgery. Other stakeholders' that must be considered is the patient themselves, as well as the adolescents' parents or guardians.

If the plastic surgeon is noted for having a reputable and ethical practice, then his or her decision to operate on a child for cosmetic reasons will be tempered by counselor recommendations, the reason the surgery is solicited, and the adolescents' readiness to handle the short- and long-term consequences of having the surgery. As previously indicated, it is not illegal for a plastic surgeon to operate on a patient under 18; so if choosing to operate, no law is broken. However, if looking solely from a business model, where good is equated to money, then the plastic surgeons action in operating on an adolescent is the morally right thing to do despite extraneous factors such as why the surgery was solicited, risks to the minor, and whether the minor is ready to address any short or long-term effects from the operation.

The rightness or wrongness of the action for the physician and/or counselor is contingent upon their involvement in the process. Their action is limited to recommendations with regard to the appropriateness of the minor for the surgical procedure. Monetarily, they gain from services rendered, and as such, once again, if money is equated to goodness from a business ethics perspective, whether their decision is in support of or against the surgery, they still benefit financially. With that in mind, merely by being a part of the process, there actions can be seen as morally good.

For parents or guardians, there is no money to be made regardless of their action. The foreseeable good is based on whose viewpoint you look to. For example, if the adolescent is desirous of plastic surgery and the parent is against it, then for a more dominant stakeholder, there is no foreseeable good in that decision. There is pain for the adolescent. What would be the motivating factor for most parents or guardians is what is best for their child; with little regard as to the impact or consequences on a societal level.

If the child is being harassed at school because of a certain physical feature, and the parent sees on a regular basis the impact this harassment is having on their child, even if they would not be in favor of teens and plastic surgery across the board, they may be more inclined to think it the right decision based on the individual needs of their child; which utilitarianism calls for.

For the adolescent, theirs is one of the more dominant considerations and as such, carries a great deal of weight. They are affected directly by the decision. For an adolescent seeking plastic surgery, whether they are responding to societal pressure to look a certain way, or reacting to personal attack from their peers and cohorts, there is the prevailing thought that the surgery will help them feel better about themselves. To that end, the action is pleasurable and it serves to minimize or eliminate possible feelings of low self-esteem. Even if there are short-term discomforts and long-term consequences, for the adolescent, the good outweighs the bad consequences, and as such is a moral right.

According to Kant, "reason is the source and ultimate basis of morality" (Cavico & Mujtaba, 2005), with his system of the categorical imperative, developed over three works: Groundwork's of the Metaphysic of Morals, Metaphysics of Morals, and Critique of Practical Reason. Through these three works, Kan developed three formulations or questions which should be asked with regard to any action before it is undertaken in order to make a determination regarding the morality of an action: (1) "Act only according to that maxim by which you can at the same time will that it would become a universal law"; (2) "Act in such a way that you always treat humanity, whether in your own person or in the person of any other, never simply as a means, but always at the same time as an end"; (3) So act as though you were, through your maxims, a law making member of a kingdom of ends."

For Kant, in order for an action to be moral it had to abide by all three formulations or pass all three rules. If the action failed at least one of the rules, then the action was considered immoral (p.115). Further, despite consequences, circumstances, and whether the achievement of a particular end was the reason, one must be moral as a command of reason.

Kant's Universal "Law" Test is a two part test. Initially, one creates a maxim and determines whether it can be a universal law for all those who are rational. Second, a determination is made whether rational beings would will the maxim to be a universal law. Once the maxim passes this two prong test, there are no exceptions. Kant's Kingdom of Ends Test is the second part of the Categorical Imperative. According to the Kingdom of Ends, every person has to be treated with dignity and respect. With this test, the intrinsic value of each person is recognized. The recognition of intrinsic value extends to each individual and the Kingdom of Ends requires each person to recognize the worth of everyone else as well as themselves (p. 117). Individuals according to this test, have the ability to make their own decision, and govern their own actions as long as they are governed by reason. Because humans are rational they are capable of recognizing and understanding moral law, responding to it in a dutiful way, and choosing to obey the law. With regard to personal desires and goals, things have value but only as a means to an end, according to Kant.

Kant's third test in the categorical imperative is the Agent-Receiver Test which raises the question whether a rational person would accept the rule regardless of whether or not the person was the giver of the action or the receiver of the action (p. 121). The action is determined immoral if a rational person would not. The third test highlights impartiality; as when a person acts on a moral rule they have to be willing to accept everyone else acting on the rule as well. This "check" against selfishness is an important part of the categorical imperative.

Unlike utilitarianism, Kantian ethics is far more abstract and lacks definitive content and precise specifications regarding moral rules. The fact that Kantian ethics promotes a society that is respective of others, and supports dignity and freedom is to be commended; however, applying this contextual framework proves difficult at best. When applied to the issue of teens and plastic surgery, the question is one of reason and rationality. Would a reasonable plastic surgeon conduct aesthetic surgery on a minor? Would a rational teen want to have aesthetic plastic surgery? Would a rational parent give consent for their child to have plastic surgery? Part of the difficulty in with relation to the Kingdom of Ends, for example, is that the test require everyone be treated as intrinsically valuable and with respect. For so many teens who consider undergoing plastic surgery, part of the reason they want the surgery is how they have been made to feel by their peers. Because those in their circle of influence do not regard them as intrinsically valuable, how then can the Kingdom of Ends argument are sufficiently applied? Inasmuch as the Kingdom of Ends applies, individuals have the ability to make their own decisions and abide by moral law. As such, it would be the teens' decision to have the surgery and the decision would be a moral one.