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Saturday, April 19, 2014

Ethics and Cosmetic Surgery

Cosmetic Surgery and Body Image

Cosmetic surgery is becoming an increasingly common surgical procedure, constituting a multibillion dollar industry and is directed overwhelmingly at female clients (Morgan 1991:25-33). According to Susan Sherwin (1996:59) it is virtually unregulated, and often poses a significant risk to clients who invest years of savings for these dangerous procedures, motivated by a culture that demands female bodies and faces to conform to a limited range of stereotypes. This practice clearly poses some substantial moral questions.

Table of Contents

1. Introduction

2. Cosmetic Surgery

3. Reasons for having Cosmetic Surgery
          3.1 Body Dysmorphic Disorder
          3.2 Teasing
          3.3 Body Image

4. Goals of Medicine

5. Enforcement of Aesthetics or Freely Adopted Lifestyle

6. Free Will
          6.1 Overview
          6.2 Modern Compatibilism: Daniel Dennet and Christopher Taylor
          6.3 Hard Determinism: Ted Honderich
          6.4 Metaphysical Libertarianism: Peter van Inwagen
          6.5 Hard Incompatabilism: Derk Pereboom
          6.6 Concluding remarks on the subject of Free Will

7. Conclusion

8. List of References

9. Declaration
  1. Introduction
Cosmetic surgery is becoming an increasingly common surgical procedure, constituting a multibillion dollar industry and is directed overwhelmingly at female clients (Morgan 1991:25-33). According to Susan Sherwin (1996:59) it is virtually unregulated, and often poses a significant risk to clients who invest years of savings for these dangerous procedures, motivated by a culture that demands female bodies and faces to conform to a limited range of stereotypes. This practice clearly poses some substantial moral questions.
In this essay I will reflect on the broad topic of cosmetic surgery, body image, and the goals of medicine. I will then consider two opposing views regarding cosmetic surgery, namely that it is either the enforcement of aesthetics, or a freely adopted lifestyle. The body of my essay will explore the issue of free will, reviewing current literature on free will. My concluding remarks will relate to whether “free will” should inform arguments either for or against cosmetic surgery.
  1. Cosmetic Surgery
According to the American Medical Association (2006) cosmetic surgery is defined as a surgical procedure undertaken to change parts of the body in order to improve the appearance and self-esteem of a patient. Haas et al (2008:178) report that 11.7 million cosmetic surgical and non-surgical procedures were performed in 2007, a 457% increase since 1997. Over the previous year they report an 8% increase in surgical procedures and that society spent $13.2 billion on cosmetic surgical procedures in 2007. The top three cosmetic procedures performed were lipoplasty, breast augmentation and blepharoplasty (surgical modification of the eyelid). The number one non-surgical procedure in 2007 was Botox injections. Their review of the literature indicates that people of all ages are electing to have cosmetic surgery, but the majority (47%) of the total is 35-50 years of age.
It would seem that the decision to have a cosmetic procedure is based on a combination of physical and psychological factors.
Askegaard et al (2002) examined what motivated women to have cosmetic surgery; some of their thoughts and feelings before, during and after the process; and the ways in which the operation influenced their life and self-identity subsequently. They found that the main physical reasons for cosmetic procedures were to improve looks or solve various types of appearance problems. These may be innate features or marks left on their bodies by the lives they had lived, consequences for example, of lifestyle, (over)eating, childbirth, or presumably, most often, the simple passage of time. They find that while people may not be planning cosmetic procedures for themselves, there is a growing acceptance of the idea that it is quite acceptable for others to seek these procedures.
Haas et al (2008:189ff) report several psychological factors to be involved in the motivation for cosmetic procedures, but find the most common to be Body Dysmorphic Disorder (BDD), body image, self-esteem and teasing.
3. Reasons for having cosmetic surgery
3.1. Body Dysmorphic Disorder
This is a psychiatric illness which consists of being excessively preoccupied with an imagined defect or a defect that is so minor that it is unnoticeable to others. People who suffer from BDD often perceive themselves as ugly and become obsessed with this perceived defect. Haas et al (2008:178) report that their review of the literature indicates that between 7-15% of cosmetic surgery patients suffer from BDD and that cosmetic surgery usually does not satisfy them and should in fact be contra-indicated in such patients.
3.2. Teasing
Haas et al’s review of the literature found a variation in results when looking at whether teasing about appearance played a role in the decision to have a cosmetic procedure. It does seem to play a role in adolescents who seek a cosmetic procedure, but is perhaps more linked to body image.
3.3. Body Image
Physical appearance is obviously a common concern of cosmetic surgery patients. In their review of the Psychology of Cosmetic Surgery, Sarwer et al (1998) find that some investigators contend that these patients obtain most of their self-esteem from their appearance and that when their self-esteem declines, they seek surgical change. Others have argued that patients are psychologically healthy “doers” who are highly motivated to improve their appearance, even with the risks of anaesthetics and surgery, as well as substantial out-of-pocket expense. The authors contend that future studies of the psychology of cosmetic surgery need to focus on body image, which they define as a “psychological construct intimately connected to physical appearance” (1998:8).They contend that body image has three principle components. The first is perceptual, reflecting a person’s estimation of body size. The second is subjective, reflecting the individual’s attitude towards his or her body. The final component is behavioural and concerns the degree to which a person’s behaviours are affected by perceptions or feelings about the body. They contend that body image should be reconceptualised as “body images” to more accurately capture the diversity of the external/objective and internal/subjective components, and that body images be defined as perceptions, thoughts and feelings about the body and bodily experiences.
Borrowing from several reviews of the psychology of body image they propose a model of relationship between body image and cosmetic surgery (see Fig 1).

Fig. 1. A Model of the Relationship Between Body Image and Cosmetic Surgery.
This model considers both physical and psychological influences on the development of body image and expands on this knowledge by specifically discussing how thoughts and feelings about appearance may influence the decision to seek cosmetic surgery.
They see the relationship between body image and cosmetic surgery as consisting of both a valence (a measure of importance to one’s self esteem) and a value (the actual degree of satisfaction or dissatisfaction with one’s body). They believe that it is the interaction between body image valence and body image value that leads to the decision to pursue cosmetic surgery. While the exact workings of their thesis is not pertinent to this essay, it does help to understand how people come to decide whether or not to pursue cosmetic surgery. Those who decide to pursue cosmetic surgery (for whatever reason) obviously have to consult a medical practitioner. I would suggest that whatever reasons a person might have for considering or pursuing cosmetic surgery, the practitioner should be guided by the goals of medicine.
4. Goals of Medicine
As shown in the previous section, the motivations for cosmetic surgery are many and varied but generally always based on a combination of psychological and emotional factors, and a significant number of people seek cosmetic surgery due to a psychiatric disorder. When a patient comes in for an initial consultation, it is important for the healthcare provider to perform an extensive history and physical examination to prevent possible psychiatric disorders from getting worse.
I would suggest that the overriding influence regarding a final treatment decision should be guided by the goals of medicine, and not the desires of the patients.
In discussing trust in medicine, Chalmers (2002:11) rightly asserts that patients expect physicians to keep their health interests ahead of business concerns and other forms of self interest and that in fact patients trust physicians to keep their health concerns first and foremost. On the subject of patient vulnerability, he states (2002:13): “When I approach a professional, I subject more than a possession of mine to that professional’s expertise: in a distinctive way, I subject myself and my future to his or her judgement. I submit myself to be determined in my future condition by the one I consult.” While he is talking about trust and not about cosmetic surgery, the statement clearly applies to our subject.
In the area of cosmetic surgery, as in all areas of medicine, the physician is called to act in the best interests of the patient. Loewy and Loewy (2004:215) point out that professionals involved with the care of patients and with making decisions about them must deal with patients of kaleidoscopically different backgrounds and beliefs; moreover these professionals have among themselves greatly differing backgrounds and world views. It is not surprising that conflicts and misunderstandings occur. Although speaking in the context of moral agency when they say: “The traditional vision of the patient-physician relationship is replaced by one in which physicians and other healthcare professionals are seen merely as competent technicians whose technical competency as well as adherence to explicit contract and bureaucratic rules define their moral duty,” this statement could describe the situation that cosmetic surgeons who are approached by the patient could find themselves in.
What is to guide decision making in cosmetic surgery? According to Loewy (2004:219) “while plastic surgeons restore what accident has shattered, they also pander to the vanity of those who do not like their appearance, or want to appear younger.” What should guide this “pandering to vanity”?
I would suggest that the goals of medicine should inform any decision regarding cosmetic procedures. The Hastings Centre Report (1992) identifies the following 4 goals:
1) the prevention of disease and injury and the promotion and maintenance of health,
2) the relief of pain and suffering caused by maladies,
3) the care and cure of those with a malady, and the care of those who cannot be cured,
4) the avoidance of premature death and the pursuit of a peaceful death.
One can foresee the sticking points being the definition of malady and the determination of suffering, but these should not be insurmountable problems.
The Charter on Medical Professionalism recognizes in its preamble that “the medical profession everywhere is embedded in diverse cultures and national traditions, but its members share the roles of healer, which has roots extending back to Hippocrates.” (2002:244). It lists 3 fundamental principles, 2 of which I wish to discuss in greater detail.
  1. Principle of primacy of patient welfare. “This principle is based on a dedication to serving the interests of the patient. Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures and administrative exigencies must not compromise this principle.” (2002:244). It is the interest of the patient (not the desire) that is important. Market forces, i.e., if I don’t do this surgery someone else will, must not dictate treatment decision. Societal pressures, i.e., a woman should look like this, must not be considered relevant to treatment planning.
  2. Principle of patient autonomy. This section covers the normal issues relating to autonomy and includes the following statement “patient’s decisions about their care must be paramount, as long as these decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.” The surgeon maintains the right (and is ethically bound to exercise it) to only carry out appropriate care. The decision regarding appropriateness is vested in the physician.

I will argue later that arguments regarding whether people (primarily women) freely choose cosmetic surgery or are in some way coerced, are irrelevant. The surgeon based on the goals of medicine and not on paternalism decides an appropriate treatment in the patient’s best interests.

  1. The charter also identifies commitment to honesty with patients as a professional responsibility of physicians towards patients, a commitment to honesty rules out any pandering to patients’ desires.

5.     The Pursuit of Beauty: the enforcement of aesthetics or a freely adopted lifestyle
Having discussed cosmetic surgery and body image I identified a number of reasons which could lead a person to desire, require or request cosmetic procedures. Then I looked at the physician’s obligations towards his/her patients with regards to the goals of medicine. My reason for doing this is to place the recommendation regarding required (cosmetic) treatment in the hands of the practitioner. Just as patients do not “request” appendectomy, heart surgery or antibiotic treatment (and if they do, the practitioner ultimately decides on a treatment plan based on the goals of medicine, which is then presented to the patient for an autonomous decision), so too should cosmetic procedures be the recommendation of the practitioner, based on the goals of medicine, rather than the desire of the patient. Many arguments around the subject of cosmetic surgery tend to focus on what motivates the patient and whether the patient is acting on a free will choice or is having some form of outside norm forced upon him/her. I will examine Henri Wijsbek’s summary of the two points of view and will then examine the subject of free will at some length, including arguments for and against its existence, and show that it is not the primary issue of consideration in the matter of cosmetic surgery.
The heading of this section is taken from an article by Henri Wijsbek (2000:454) in which he asks whether women are having cosmetic surgery because they are duped by a male dominated beauty system or because they genuinely choose these operations for themselves. He examines a feminist perspective by critiquing Kathryn Morgan’s (1991) Women and the Knife. He summarizes her paper as saying that women seek cosmetic surgery in order to conform, that they see their bodies as raw material and that they experience overwhelming pressure to undergo cosmetic surgery - these all lead to a “paradox of coerced voluntariness and a technological imperative.” (Wijsbek 2000:454)
Morgan herself (1991:47) concludes her thesis by describing the culture she lives in as one that “defines femininity in terms of submission to men, that makes the achievement of femininity … obligatory of any woman … and that requires women to purchase femininity through submission to cosmetic surgeons.” It is her belief that women do not act according to their free will when submitting to cosmetic surgery.
Wijsbek provides an opposing argument in the form of Kathy Davis’ Reshaping the Female Body (1995, published by Routledge, New York) who, according to him (I couldn’t access the book) stresses women’s agency and free will leading to un-coerced decisions regarding cosmetic surgery. He then goes to great lengths to examine the issues from the point of view of agency and free will and does not come to any firm decision, exemplified by his final concluding heading: “lingering doubts ” in which he expresses uncertainty regarding which argument carries more weight.
It is my argument that the issue of free will in this context is a red herring. As already pointed out, patients should be having cosmetic surgery based on the surgeon’s recommendations in accordance with the goals of medicine. The issue should be one of informed consent, with the onus on the practitioner to provide information, rather than informed request on the part of the patient. Wijsbek does ask the question: “Is cosmetic surgery reprehensible?” but fails to even attempt to answer it. As long as the focus is on the free will of the person requesting cosmetic surgery, that question will remain unanswered.
So why do I suggest that free will is a red herring in this context?
6.     Free Will
6.1. Overview
“The problem of free will and necessity (or determinism) is perhaps the most voluminously debated of all philosophical problems. This situation has not changed at the end of the 20th century and the beginning of a new millennium. Indeed debates about free will have become more voluminous in the past century, especially the latter half of it – so much so that it has become difficult to keep up with the latest developments.” (Kane 2002:3) According to O’Connor (2011) “free will is a philosophical term for a particular sort of capacity of rational agents to choose a course of action from among various alternatives. Which sort is the free will sort is what all the fuss is about. And what a fuss it has been: philosophers have debated this question for over two millennia, and just about every major philosopher has had something to say about it. Most philosophers support that the concept of free will is very closely connected to the concept of moral responsibility. Acting on free will, on such views, is just to satisfy the metaphysical requirement of being responsible for one’s actions. But the significance of free will is not exhausted by its connection to moral responsibility. Free will also appears to be a condition in desert for one’s accomplishments; on the autonomy and dignity of persons; and on the value we accord to love and friendship.”
The online encyclopaedia, Wikipedia (2011) gives a good overview of the various stages in 21st century debates regarding free will. I will summarise their overview and then look at some arguments in favour of some of the main stances.
Free will can be defined as the apparent ability of agents to make choices free from certain kinds of restraints. Historically, the constraint of dominant concern has been the metaphysical constraint of determinism. Determinism is the concept that events within a given paradigm are bound by causality in such a way that any state is completely or at least to some large degree, determined by prior status. It conjectures that every type of event, including human behaviour, decision and action is causally determined by previous events. When causal determination is seen as the relevant factor in the question of free will, the position is classified as incompatibilist. When determinism is not regarded as the relevant factor in the question of free will, the position is classified as compatibilist. Compatibilistsoffer various other alternative explanations of what constraints are relevant, such as physical constraints (e.g., chains or imprisonment), social constraints (e.g., threat or punishment or censure), or psychological constraints (e.g., compulsions or phobias). The principle of free will has religious, ethical and scientific implications. In ethics, it may hold implications for whether individuals can be held morally accountable for their actions.
Incompatibilism is the position that free will and determinism are logically incompatible and that the major question regarding whether or not people have free will is thus whether or not their actions are determined. Hard determinists are those who accept determinism and reject free will. Metaphysical libertarians are those incompatibilists who accept free will and deny determinism, holding the view that some form of indeterminism is true. Indeterminism is the concept that events are not caused deterministically from prior events.
Another view is that of hard incompatibilism, which states that free will is incompatible with both determinism and indeterminism.
Compatibilists maintain that determinism is compatible with free will. They argue that determinism does not matter, what matters is that an individual’s will is the result of the individual’s own desires, not over-ridden by some external force. To be a compatibilist one need not endorse any particular conception of free will, but only deny that determinism is at odds with free will.
From the above, it seems that philosophers’ views regarding free will can be classified as either compatibilist or incompatibilist. Daniel Dennet is a modern compatibilist, Ted Honderich a hard determinist, Peter van Inwagen and Robert Kane are metaphysical libertarians and Derk Pereboom, a hard incompatibilist.
Before looking at each of their stances in a little more detail, it is important to note that some philosophers’ views are difficult to fit into the above-mentioned categorisation. John Locke, for example, denied that the phrase “free will” made any sense and that the truth of determinism was irrelevant. He believed that the defining feature of voluntary behaviour was that individuals have the ability to postpone a decision long enough to reflect or deliberate on the consequences of a choice: “… the will in truth, signifies nothing but a power, or ability, to prefer or choose.” (Locke 1689)

6.2. Modern Compatibilism: Daniel Dennet and Christopher Taylor
In a paper entitled “Who’s afraid of determinism? Rethinking causes and possibilities” Dennet and Taylor (2002) ascertain that incompatibilism subsists on two widely accepted but “deeply confused” theses concerning possibility and causation: Firstly that in a deterministic universe, one can never truthfully utter the sentence “I could have done otherwise”; and secondly, that in such universes one can never really take credit for having caused an event, since in fact all events have been pre-determined by conditions during the universe’s birth. Their argument seems more directed at proving incompatibilism wrong, than proving compatibilism correct. They suggest that incompatibilists dread determinism because they suspect that a deterministic universe would lack the sorts of open possibilities that we cherish and would deprive us of the ability to cause changes to the world in a meaningful way. They therefore (i.e. incompatibilists) find heartening the discovery of indeterminacy in modern quantum mechanics and they hope to find indeterministic quantum events at the root of each free agent’s decision-making ability. Dennet and Taylor re-examine the foundations of possibilities and causes and proceed to show that the desire to have power to effect changes can be satisfied without any recondite appeals to quantum indeterminacy. Much of their argument rests on referring to the field of computer science and showing how deterministic computer algorithms can adapt themselves to changes in the environment and learn from their mistakes.
They show (to their satisfaction, but to my mind somewhat unconvincingly) that the ability to author something of original value is independent of determinism.
6.3. Hard Determinism: Ted Honderich
 Honderich (2002:461) considers compatibilism’s argument that our freedom consists in voluntariness, doing what we desire and not being coerced; hence its conclusion that determinism and freedom go together. He also examines incompatibilism’s argument that our freedom consists in origination or free will, our choosing without our choosing’s being coerced; hence the conclusion that determinism and freedom are inconsistent. He argues that both views are mistaken, since freedom as voluntariness and freedom as origination are each fundamental to our lives. The real problem of the consequences of determinism is not choosing between the two traditional doctrines, but a more practical one: trying to give up what must be given up, since we do not have the power of origination.
6.4. Metaphysical Libertarianism: Peter van Inwagen
Van Inwagen (2002:158) argues that the thesis that free will and determinism are compatible is implausible. His standpoint is that free will undeniably exists but is incompatible with determinism and seems incompatible with indeterminism. For him this presents a mystery which he resolves by suggesting that free will is perhaps not incompatible with indeterminism. He feels that although the arguments for the incompatibility of free will and indeterminism are plausible and suggestive, they are not watertight. Many philosophers are convinced that the theory of agent causation shows that acts are undetermined by past states of affairs and can be free acts. He acknowledges that enemies of the idea of agent causation are numerous and articulate and that their arguments are based on one or the other of two convictions: that the concept of agent causation is incoherent, or that the reality of agent causation would be inconsistent with naturalism or a scientific worldview. He then suggests that the concept of agent causation is useless to the philosopher who wants to maintain that free will and indeterminism are compatible. He doesn’t try to show that the concept of agent causation is incoherent or that the real existence of agent causation should be rejected for scientific reasons. He assumes “for the sake of argument” (2002:159) that agent causation is possible and that it in fact exists and then presents argument for the conclusion that free will and indeterminism are incompatible even if our acts or their causal antecedents are products of agent. He suggests there is no way to respond to this argument and concludes that free will remains a mystery – it undeniably exists and that there is a strong and unanswered prima facie case for its impossibility.
6.5. Hard Incompatibilism: Derk Pereboom
The central thesis of the position Pereboom defends (2002:477) is that we do not have the sort of free will required for moral responsibility. His argument for this claim has the following structure. An agent’s moral responsibility for an action depends primarily on its actual causal history and not on the existence of alternative possibilities. Absent agent causation, indeterministic causal histories pose no less of a threat to moral responsibility than do deterministic histories, and a generalisation argument from manipulation cases shows that deterministic histories indeed undermine moral responsibility. Agent causation is a coherent possibility, but it is not credible given our best physical theories. Consequently, no position that affirms the sort of free will required for moral responsibility is left standing. He contends that a conception of life without this sort of free will would not be devastating to our sense of meaning and purpose, but in certain respects may even be beneficial. He concedes that although his position is clearly similar to hard determinism, it doesn’t endorse determinism itself. He therefore chooses to call his position hard incompatibilism.
6.6. Concluding remarks regarding free will
In his introduction to the Oxford Handbook of Free Will, Robert Kane (2002:9) recognizes that while determinism has been in retreat in the physical sciences during the 20th century, developments in sciences other than physics – in biology, neuroscience, psychology, psychiatry, social and behavioural sciences – have been moving in the opposite direction. They have convinced many persons that more of our behaviour is determined by causes unknown to us and beyond our control than previously believed. These scientific developments are many, but include a greatly enhanced knowledge of the influence of genetics and heredity upon human behaviour; greater awareness of biochemical influences on the brain; the susceptibility of human moods and behaviour to drugs; comparative studies of animal and human behaviour suggesting that much of our motivational and behavioural repertoire is a product of our evolutionary history and so on.
“In sum, there continues to be considerable debate about determinism and indeterminism in the physical world, and about the relationship of both to human behaviour, while contemporary sciences other than physics provide continuing support for deterministic thinking about human behaviour. Worries about determinism in human affairs therefore persist with good reason in contemporary debates about free will.” (2002:9)
7.     Conclusion
Cosmetic surgery is a growing, multibillion dollar, worldwide enterprise, aimed primarily at female clients and often posing significant risks. I have explored some of the reasons behind people requesting cosmetic procedures and shown a link between body image and cosmetic surgery. Having explored some of the external influences that affect body image, I summarized two arguments: one suggesting that cosmetic surgery is a freely adopted choice, the other that it is an enforced lifestyle involving no (or very little) freedom on the part of the agent. In exploring current thought on the subject of free will, I have shown that there is no unanimity on the subject; perhaps free will does exist, perhaps free will doesn’t exist. The arguments either way are not conclusive, although in my opinion, the arguments against free will existing are stronger and more coherent than the arguments in favour of free will.
For this reason I suggest that regarding the topic of cosmetic surgery, debate around the free will of the client is a red herring. The ethical issue is not whether the client is acting as a free agent in requesting cosmetic surgery, but rather whether the surgeon is presenting a treatment plan based on the ethical goals of medicine.

8.     List of References

American Medical Association. 2006. Available: Accessed 19/4/2011

Askegaard, S., Gertsen, M.C., Langer, R. 2002. The body consumed: Reflexivity and cosmetic surgery. In Psychology & Marketing, 19 (10): 793-812 Available: Accessed: 12/03/2011

Chalmers, C.C. 2002. Trust in Medicine. In: Journal of Medicine and Philosophy 27(1):11-29 [Binder]

Charter on Medical Professionalism. 2002. Project of the ABIM Foundation, ACP-ASIM Foundation and the European Federation of Internal Medicine.  In: Annals of  Internal Medicine, 136: 243-6. Available:  Accessed: 12/03/2011

Dennet, D., Taylor, C. 2002. Who’s Afraid of Determinism? Rethinking Causes and Possibilities. In: The Oxford Handbook of Free Will. Robert Kane (Ed). Oxford: Oxford University Press (257-280)

Hastings Centre Report. 1992. The Goals of Medicine: Setting new priorities. 26:1-27 [Binder]

Honderich, T. 2002. Determinism as True, Compatabilism and Incompatabilism as False, and the Real Problem. In: The Oxford Handbook of Free Will, Robert Kane (Ed). Oxford: Oxford University Press (461-477)

Kane, R. (Ed). 2002. The Oxford Handbook of Free Will. Oxford: Oxford University Press

Locke, J. (1689). An Essay Concerning Human Understanding (1998, ed). Book II, Chap. XXI, Sec. 17. Penguin Classics, Toronto. In: Wikipedia. Available:  Accessed 27/04/2011

Loewy, E., Loewy, R.S. 2004. Textbook of Healthcare Ethics. New York and London: Phenium Press.

O'Connor, T. Free Will. In: The Stanford Encyclopedia of Philosophy (Summer 2011 Edition), Edward N. Zalta (ed.), forthcoming URL =
Pereboom, D. 2002. Living without Free Will: The Case for Hard Incompatabilism. In: The Oxford Handbook of Free Will, Robert Kane (Ed). Oxford: Oxford University Press (477-488)

Sarwer, D., Waddena, T.A., Pertschuka, M.J., and Whitakera, L.A. 1998. The Psychology of Cosmetic Surgery: A Review and Reconceptualisation. In Clinical Psychology Review, 18 (1): 1-22. Available:  Accessed: 12/03/2011

Sherwin, Susan. 1996. Feminism and Bioethics. In: Feminism and Bioethics beyond reproduction. Susan Wolf (Ed). New York: Oxford University Press: 47-66.

Van Inwagen, P. 2002. Free Will Remains a Mystery. In: The Oxford Handbook of Free Will, Robert Kane (Ed). Oxford: Oxford University Press (158-180)

Wijsbek, H. 2000. The Pursuit of beauty: the enforcement of aesthetics or a freely adopted lifestyle? In: Journal of Medical Ethics 26:454-458 [Handout]

Wikipedia. 2011. Available:  accessed: 27/04/2011

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