The Ethics of Plastic Surgery
Our mirror image - a mirror of society
Views about cosmetic plastic surgery differ widely: Is it an empowering tool for people to become more confident in their own skin? A right that stems directly from our right over our own body? Or is it an unethical exploitation of (mostly) women, intersecting with issues of classism, racism, ableism, lookism, and misogyny?
I think the cosmetic plastic surgery industry has lots (!) of issues, some of which I will highlight in this newsletter. But, I also think that personal rights, especially our right over our own body, and our right to autonomy and privacy, add an often overlooked nuance to the debate. Ultimately, I think any discussion surrounding plastic surgery should start from a point of compassion, rather than judgment. I hope this will become clearer throughout this post.
Note, none of this discussion is meant to apply to reconstructive plastic surgery, whose invaluable contributions often get overlooked in the debate.
Our mirror image - A mirror of society?
It is a fair criticism to suggest we live in an appearance obsessed society: In 2023, the global cosmetic surgery industry was valued over $50 billion, and it is expected to rise to over 80 billion by 2032 (Fortune Business Insights, 2024). Many factors help explain this trend, and intersect with existing societal problems. Here are just a few:
Increasingly young people want to get plastic surgery: In the UK, around half of Gen Z and millennial women have considered cosmetic treatment (Cosmetic Surgery Solicitors). They often cite social media as an influencing factor, where plastic surgery gets promoted ruthlessly to teenagers as young as 14 (Zither, 2021). As a result, many see getting fillers as something as benign as getting a new haircut.
Our pervasive fear of getting older, which reflects a devaluing of (especially) women, as they get older (Hurd, 1999). Gen Zs seem especially concerned with this, with preventative botox being advertised to 20 year olds (Kennedy, 2023)
The "you're not ugly you're just poor" trend on social media, especially TikTok, highlights how expensive ‘achieving’ beauty (as it is currently defined) is (and this is not only because of the cost of plastic surgery). This makes achieving a certain look inaccessible for most.
Medical Tourism, where individuals travel to (mostly) cheaper countries is booming, given that many people can't afford plastic surgery in their home country but still feel the strong pressure to fit a certain ideal (Raggio et al., 2020). Yet, regulations and standards in treatment also differ globally, and patients seeking cheaper often unlicensed practitioners are at a much higher risk for complications (as e.g. this tragic personal story shows (Note: Graphic Content)).
Societal expectations can be especially strong for people of colour/ ethnic minorities. Many popular plastic surgeries such as double eyelid surgery and rhinoplasty have been accused of 'whitewashing' ethnic features, further entrenching Eurocentric beauty standards (O’Connor, 2014; Manon, 2023).
Women make up 92% of patients undergoing cosmetic plastic surgeries, showing how it is still mainly women who need to be pretty to be seen as worthy (ASPS, 2020). However, men are certainly not immune to societal beauty standards and are increasingly undergoing procedures (Lem et al, 2023; BAAPS, 2023).
The pervasiveness of 'pretty privilege', where people deemed 'pretty' get all sorts of benefits (Spiegel, 2022).
Filters, make-up, plastic surgery and deep fakes raise beauty standards and make it increasingly difficult to know what is real/ accept how one looks in real life. Natural beauty is slowly becoming extinct. We want to look like our filtered selves, a phenomenon coined as “Snapchat Dysmorphia”.
Having this wider societal context in mind, I will now discuss the role and ethical challenges surrounding specific individuals, namely plastic surgeons and public figures.
Obligations of plastic surgeons
Plastic surgeons are bound by medical ethics. Three principles underlying medical ethics - autonomy, nonmaleficence and beneficence - are especially relevant in this context (Gillon, 1994). However, they can point in opposite directions (Roubaix, 2010).
The principle of autonomy requires doctors to respect the self-determination of competent adults to make decisions about their bodies. Some feminists such as Morgan (1991) argue that plastic surgery is “externally imposed” because of society's oppressive beauty standards, and thus never an autonomous choice . Yet, I think this stance is too paternalistic and even condescending, as it assumes that competent women are unable to make informed choices. What is true, however, is that the decision to undergo plastic surgery is often made with insufficient understanding of the risks involved. Whilst surgeons make an effort to disclose all relevant risks, less focus is placed on ensuring patients actually understand these (Hagopian et al, 2020). Ensuring truly informed consent will require a higher standard of patient education and decision-making support (Latham, 2010).
The principle of non-maleficence – the duty to avoid harm – kicks in if surgeons believe plastic surgery to harm the patient. If a surgeon foresees a significant risk of harm, they ought to, in my opinion, refuse surgery. Whether harm encompasses only safety risks, or also a worsening of the patients aesthetic appearance is a further question. Whilst minor differences in aesthetic preference may not warrant a refusal of performing surgery, in many cases, e.g., in individuals who became addicted to plastic surgery, the differences can be very significant. And given that the surgery is a) not for medical purposes, but on the contrary comes with its own medical risks and b) a surgeon's reputation hangs on the line when conducting “botched” surgeries, I think leeway in declining to perform is necessary.
The principle of beneficence requires doctors to act in the best interest of their patients. A study by Joseph et al. (2017) found that 13.1% of cosmetic plastic surgery patients met diagnostic criteria for Body Dysmorphic Disorder (BDD) (compared to the population average of roughly 2%). There is strong evidence that patients suffering from BDD don’t benefit from surgery (Joseph et al., 2017). Once one ‘issue’ is fixed, a new one is often found. Psychological screening before surgery is therefore critical (Nejadsarvari & Ebrahimi, 2014).
Overall, plastic surgeons should respect the principles of autonomy, non-maleficence and beneficence, not sell unrealistic outcomes, and have the integrity to refuse plastic surgery even if this hurts their bottom line.
Public figures who underwent plastic surgery
That many celebrities and influencers undergo plastic surgery is common knowledge by now. Yet, we still compare ourselves to them. In public discussions, I think they are often dismissed for being vain and the culprits behind unattainable beauty standards. I think this description is too simplistic and as a result unfair. As the same criticisms are at time also used against private individuals getting plastic surgery, my explanation of why I think more nuance is needed hence also applies to them.
Whilst I don’t know the true reasons for why any public figure has undergone plastic surgery, they are caught in a tricky double-bind: Their appearance is constantly scrutinized and criticized. Any ‘flaw’ will be prayed on. Yet, when they ‘fix’ the flaw, they will be further scrutinized and criticized: If they stay silent about their procedure they will be criticized for promoting unrealistic beauty standards and being fake. And if they are open about the procedure, they are criticized for advertising plastic surgery to impressionable young fans. They seemingly can’t get it right.
I think there are varying degrees of getting it wrong so I certainly don’t want to justify all their decisions. But I think looking at the issue with compassion, rather than judgment, will get us all further.
Firstly, I think we should remember that also for celebrities with access to the best plastic surgeons, surgery comes with risks (medical and aesthetic). I therefore find it hard to imagine that someone would repeatedly undergo invasive procedures unless they themselves suffer from deep insecurities. Whilst this doesn’t negate the fact that they are thereby further perpetuating toxic standards, I think they are also ‘victims’ of said standards. Perhaps even more so than the general public, given how much time they have to spend looking at themselves. The “Zoom Boom” in cosmetic surgeries during the Pandemic resulted in an increase in middle aged men getting procedures, because they increasingly noticed ‘flaws’ when looking at themselves during meetings (Renwick, 2021). I think this shows that there isn’t something uniquely vain about public figures.
Secondly, when it comes to speaking about one's surgeries, I believe there is a difference between actively denying one underwent surgery, and not speaking about the issue. Lying is ethically wrong. Whether not opening up about one's surgery is wrong is I think more difficult to judge. Public figures, like all of us, still have a right to privacy. As medical procedures of any kind are highly sensitive, I don’t think they have an obligation to speak about it. This doesn’t mean others can’t speak about it, as the by now countless youtube videos of plastic surgeons analysing celebrity faces show (e.g. by Dr Gary Linkov). I also think transparently communicating about what procedures one has gotten done would be morally preferable. Here however, the manner of communication matters: If risks aren’t clearly presented, the boundary between raising awareness and advertising a procedure gets blurred. I find promoting plastic surgery is wrong, and unacceptable where one derives undisclosed profits from it. In the case of influencers this often means getting surgery done for free/ at a reduced cost in exchange for recording ones’ procedure on Social Media and promoting the clinic (Tenbarge, 2022).
I hope this brief discussion highlighted how tricky it is to communicate appropriately about plastic surgery. Should a public figure choose to speak about their plastic surgery, they should do so with honesty: about the fact they have gotten surgery, the risks involved, and any financial benefit they derive from it.
Looking into the future
Just as we should treat people undergoing plastic surgery with compassion, we should treat ourselves with compassion. I think a key part of this is seeing our appearance as only one aspect of ourselves, and certainly not the most important one. As Robin Sharma’s famous saying goes:
What you focus on grows, what you think about expands and what you dwell upon determines your destiny.
To conclude, our appearance is increasingly changing from something we are ‘born with’ to something we can actively co-create. The Ship of Theseus thought experiment asks whether an object that has had all of its components replaced remains the same object: How much can we change our appearance before it changes us?
Thank you for reading and all the best,
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