In the past decade, socially-constructed notions of beauty have stimulated demand for cosmetic surgery procedures. at the same time, technological advances in medical procedures give patients more options for elective cosmetic surgery while reducing the likelihood of negative outcomes. A typical patient, however, usually is not fully aware of the risks and long-term consequences of cosmetic surgery. to narrow the information gap between doctor and patient, anyone about to undergo such surgery must be able to rely on his or her physician for clear, complete, and honest information about the procedure.
The doctor-patient relationship relies on informed consent: A patient agrees to a procedure only after considering information provided by a physician. Since the average patient’s decision is based largely on information selected and presented by the doctor, the nature and extent of that information is crucial.
The doctrine of informed consent seeks to ensure that patients considering surgery receive sufficient information about their procedures, including potential risks, consequences, and alternatives. Surgeons are held accountable for disclosing this information by the legal safeguard of negligence liability for falling below the standard of care. but medical malpractice lawsuits are second-best remedies for insufficient patient information. Addressing the lack of patient information only after a negative outcome is both inefficient and unsatisfactory and therefore motivates exploring preventative measures.
Better approaches to improving medical communication are especially appropriate for elective cosmetic surgery, which differs from other surgery in its lack of medical necessity, the greater financial conflict of interest for the surgeon, the inaccurate public perception of risks, and patients’ unreasonable expectations. these differences warrant further precautions in a culture where beauty is a social priority and the number of cosmetic surgical cases increases annually.
The human inability to appreciate low probability events diminishes the perceived risks of activities such as driving, drinking heavily, and undergoing cosmetic surgery. Furthermore, inherent misperceptions about medical risks pose a particular problem for patients undergoing cosmetic surgical procedures, as opposed to other elective surgeries, since the media downplays the risks of cosmetic surgery, making potential patients feel immune to the considerable risks that do exist. Indeed, the media generates a common misconception that cosmetic surgery is a foolproof, risk-free method of self-improvement. popular television shows such as “Extreme Makeover” and “The Swan” glorify surgically-achieved beauty without mentioning risks such as numbness, infection, and even death.
These media programs also fail to address the long recovery time and psychological dissatisfaction or regret that patients may feel post-surgery. as a result, people feel strong pressure to alter their looks and conform to a socially-constructed notion of beauty. not surprisingly, in 2004, over 9 million surgical and non-surgical cosmetic procedures were performed in the United States, a 5% increase from 2003.
A patient’s underlying motives for undergoing surgery are also important in distinguishing elective cosmetic surgery. Elective non-cosmetic surgeries are performed to restore proper function or relieve pain, and therefore they are fundamentally different from cosmetic surgeries, which serve only to address issues of vanity. Similarly, reconstructive cosmetic surgery differs from other cosmetic surgery because it aims not to enhance normal appearances, but only to restore appearance to the status quo.
Patients for elective cosmetic surgery may be motivated by unreasonable expectations and the desire to obtain physical perfection. This problem is particularly acute for patients with body dysmorphic disorder (BDD) who have unrealistic and negative views of their relatively normal appearance.
There thus exists an information asymmetry in cosmetic surgery: the patient lacks the physician’s knowledge and the physician does not know under what conditions the patient will be satisfied. the physician, therefore, cannot function as a perfect agent for a patient, not only because the physician’s own financial interest creates a conflict, but because what constitutes a medically successful outcome to a surgeon may not coincide with a patient’s subjective interpretation of success.
Furthermore, information presented to patients contemplating elective, cosmetic surgery is likely to be particularly influential, since by definition the procedure is not medically necessary. the patient truly has a choice to refuse treatment without incurring any medical harm. While physicians have a legal obligation to ensure patient safety, that obligation generally does not include deterring patients from basically safe but unnecessary and avoidable procedures. Since cosmetic surgery is driven by choice, physicians have more influence over a patient’s ultimate decision.
These various aspects of elective cosmetic surgery justify considering additional interventions for increased disclosure and informed consent requirements. Simple preemptive interventions might help patients from ultimately regretting the decision to undergo surgery.
An inexpensive, yet effective means of supplying clear information to patients is mandatory distribution of standardized literature about cosmetic surgical procedures. upon consultation with a plastic surgeon, potential patients could receive literature detailing their chosen procedure, risks, alternatives, expected recovery time, typical pain during recovery, and feedback from patients who already have undergone similar surgery and experienced a range of results.
Distribution of such sources offers various benefits to patients, since it would not only increase their access to information, but also reiterate the realities of cosmetic surgery that often get overlooked in popular media. Creating and dispensing such literature is also relatively inexpensive, especially as the costs would be spread over a large number of users. A standardized pamphlet could be developed by specialized, highly competent physicians and distributed nationwide in various languages.
Surgeons ought to have few objections to such an intervention, as it would simplify their burden of disclosure. Moreover, additional literature might even prevent malpractice lawsuits, since patients would have difficulty claiming violation of informed consent. the published information might also generate more realistic patient expectations, which would reduce the information asymmetry problem. One danger, however, is that reliance on written information may discourage patients from one-on-one personalized discussions with their doctors, or from seeking a second medical opinion under the belief that another surgeon might not offer new insight or advice not included in the standardized literature.
While written information increases patient understanding and awareness, visual information through pre- and post- surgical photographs or videos might also be required for proper informed consent before cosmetic surgery. the pictures presented to a potential patient would have to depict successful and average cases as well as bad outcomes.
Visual disclosure would allow a patient to make a well-informed decision to undergo cosmetic surgery only after assessing a reasonable range for the primary result of such surgery—namely, appearance. A patient may be warned in verbal or written form of potential negative outcomes, but seeing photographs of real cases unambiguously presents the potential results.
A counter-argument to distributing such photographs is that they might be considered sensational and do not convey any probability of the specific outcome in a particular case. Still, distribution of both literature and photographs is a cost-effective, standardized method that can reduce the subjectivity of informed consent. and a physician remains obligated to deal with each individual patient and that patient’s unique physical and emotional character. Thus, physicians should not rely too heavily on the literature and photographs, which may not apply to every patient.
Proper informed consent also includes accurate knowledge about one’s surgeon. Choosing a capable, experienced surgeon is critical when undergoing cosmetic surgery, especially since legally a physician need not be a plastic surgeon to perform cosmetic surgery. This lucrative business has attracted many physicians who are unqualified in the field of plastic surgery.
To provide meaningful information concerning a physician’s education and training, physicians should be required to disclose their histories and success rates. This would make cosmetic surgery a more competitive field in which patient demand would eliminate doctors who lack the appropriate experience and skill to perform cosmetic surgery. and disclosure of physician history would be relatively inexpensive after initial compilation, since it requires only minimal time for updating from the surgeon and periodic verification from an objective source.
Complete disclosure offers incentive for surgeons to make patient safety their ultimate priority, since successful outcomes are directly linked to attracting future patients. Moreover, mandatory admission of error would elicit more open discussion among medical professionals about how and why the error occurred and how it could be prevented in the future.
Problems might arise, however, if all of a surgeon’s disappointing outcomes had to be disclosed. Physicians would be deterred from undertaking the difficult cases that are likely to have lower success rates. This would create a dilemma for patients with complications from prior surgery who are more likely to have problems with subsequent procedures. Still, increased openness would be an important incentive for patients to learn as much as reasonably possible about the potential errors, risks, and unexpected consequences of cosmetic surgery that particular surgeons have experienced.
Another option to prevent patients from undergoing cosmetic surgery without fully considering and appreciating the risks is to mandate that they have time to be reflective about their decision. This could be achieved by enforcing a restriction on patient access to cosmetic surgical procedures until they receive a second opinion. Such a ‘cooling off’ period would prevent over-eager patients from rushing into unnecessary and perhaps unwise surgery. Especially during an era in which advertising and the media greatly influence people’s self-image, the pressure to use all means to attain physical perfection may cloud patients’ capacity to properly consider the benefits and risks of surgery. Consulting a second surgeon before undergoing the procedure gives the patient more time for realistic expectations to solidify.
The consequence of the cooling off period, however, would be to impose impediments in terms of time, money, and the utilization of medical resources. the immediate costs are borne by the patient and physician. A cooling off period validates the notion that cosmetic surgery is a serious undertaking and prevents patients from lackadaisically undergoing cosmetic surgery. but this is the most paternalistic of the interventions mentioned, and it may be criticized for infringing on people’s individual freedoms.
The U.S. Supreme Court has ruled that an analogous 24-hour waiting period for a woman wanting an abortion is not too burdensome even though access to abortion, unlike elective cosmetic surgery, is a constitutional right. the 24-hour waiting period for an abortion has its most deleterious effect on those women least able to bear its burden. In contrast, most elective, cosmetic surgery patients tend to be from the upper socio-economic levels of society with the resources to pay for procedures often not covered by health insurance. Still, the barriers and burdens introduced on the cosmetic surgery patient by the cooling off period may be too great to make this a mandatory, as opposed to a highly recommended, prescription.
The medical profession reaps obvious benefits from the increased demand for cosmetic surgery, but patients overall may not be well served. Yet modern medicine offers many wonderful treatments for real and perceived problems, and we should not lightly deny people the freedom to avail themselves of what science and technology have to offer. So, in keeping with modern developments regarding patient autonomy and informed consent, we can improve the process by which patients decide to undergo elective cosmetic surgery. relatively modest improvements in the communication of information such patients receive from their physicians can considerably benefit all concerned—patients, doctors, and society at large—without imposing undue costs and without infringing upon important elements of individual freedom.