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
- 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.
- 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.
- 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.
- 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.
- 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
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Gertsen, M.C., Langer, R. 2002. The
body consumed: Reflexivity and cosmetic surgery. In Psychology & Marketing, 19 (10): 793-812
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