By S. Van McCrary, Health Law & Policy Institute
Recently, media attention has been focused on certain types of cosmetic surgery that are rapidly increasing among adolescent females in the United States. This trend raises disturbing ethical issues for the surgeons faced with young, impressionable patients.
Although surgery to reshape the nose is still the most frequent, other procedures have increased rapidly since 1992. These include breast augmentation, collagen injection, eyelid surgery, liposuction, and "tummy tuck." Most surgeons agree that procedures such as nose reshaping or pinning the ears back are appropriate for adolescents with awkward features. In contrast, the other procedures mentioned above are substantially more controversial in the medical community when the surgery is contemplated by teenagers.
Decisional capacity of the minor and avoidance of coercion are at least two general categories of ethical issues in this controversy that must be confronted by both physicians and patients. First, minors are not generally considered ready to make such decisions either by social convention or law. (Occasional exceptions have been recognized--for example, terminally ill children for whom conventional treatments have failed are sometimes permitted to refuse further burdensome treatment.) Also crucial is the tremendous influence that social pressure from the advertising and entertainment media can have on susceptible young persons. This is not to say that all adolescents lack decisional capacity, but rather that many adolescents are subject to vicissitudes of mood that change often and unpredictably, and as a consequence, they may require assistance with prudent consideration of all the relevant benefits and burdens of surgery.
Second, parents of teens can also be affected by media-induced social pressures and ideal images of the body, and may be in a position to have an undue influence on a childís decision. Careful discussions and observations by physicians may detect potential for parental coercion. For example, if the physician asks the patient "Why donít you like your ears?" and the child responds "My father thinks theyíre too big," there may be a serious problem. It is crucial for physicians in similar circumstances to protect the child from the parentís wish. To do otherwise would allow the child to be treated as an object rather than an autonomous moral agent.
Each of these types of ethical issues should be considered by the individual physician when counseling an adolescent seeking invasive cosmetic procedures. Fortunately, numerous doctors have developed plans for dealing with requests they consider inappropriate, such as imposing a waiting period to allow the possibility of a change of mind, careful scrutiny of the parent-child relationship to evaluate potential coercion, and consultation with the adolescent without the presence of parents. All plastic surgeons would be well advised to adopt such vigilant screening practices when dealing with young patients requesting cosmetic procedures.
Thoughtful commentary on similar issues is found in a recent book by Mary G. Winkler and Letha B. Cole, entitled The Good Body: Asceticism in Contemporary Culture (Yale University Press, 1994). In her chapter entitled "Model Women," Dr. Winkler calls for a social reconceptualization of the body. She notes: "We need to review the tensions in our society between wholesome self-regard and selfishness, between the human need for love and approval and autonomy, between our enjoyment of life and our fear of death, between delight in the body and hatred of the flesh . . . ." Readers interested in pursuing this line of inquiry may benefit from perusing Dr. Winkler and Coleís book.