Bioethics Forum Essay

Medicine Needs a Declaration of Independence from Cosmetic Procedures

What is medicine for? I found this question on my mind recently, not only because I had been discussing it with a group of thoughtful medical students to whom I was teaching the history of medicine, but also because I was shopping for a bra at Bloomingdale’s.

On my lunch break, I found myself alongside a mother buying her teenage daughter new bras. The girl needed new bras, because her mother had just bought her new breasts. The mother’s loud bragging about the surgeon’s finery had me cringing in the dressing stall.

Is this what medicine is for?  Mamas boasting about their babes’ boobs? I don’t think so. I’m not naïve; as an historian of medicine, I know that medicine has always advanced itself by offering improvements of patients’ social status, primarily by making patients healthier, but also by legitimizing their complaints.

But the noble profession has historically been primarily about something nobler than boob jobs and Botoxing wrinkles. The medical profession’s primary goal, historically speaking, has been prevention and relief of real suffering.

I can’t believe I even have to assert that. If the great men and women of medicine could come back from the dead and watch television today, what would they make of the fact that a large percentage of the medicine that is represented is cosmetic?

They might conclude, reasonably, that this reveals medicine’s success. Only in a world of astonishingly good anesthetics, infection management, and surgical technique would patients dare seek these procedures. But they might also reasonably conclude that something very strange has happened.

In a world where drugs are tested rigorously before they are permitted, here are all these risky “medical” procedures which have almost no evidentiary claim to being necessary or effective, unless by “necessary” and “effective” we simply mean satisfying the demands of a “consumer” we used to recognize as a patient.

I know, these procedures are offered in the name of patient autonomy. But as any first-semester ethics student understands, real autonomous choice requires knowledge, and it does not appear that many patients who are literally sold the belief that these procedures will improve their lives have been told that what little evidence we do have suggests their hopes are false.

Imagine if a patient came in and said “I think my cholesterol is probably high because I saw your advertisement and the actor looked like me, and so I want drug X because I want to feel better like the actor did,” and the doctor simply said, “OK! You’re autonomous!” and gave the prescription?

That idea makes an internist’s skin crawl. I know; I’m married to one – one I actually dragged to a “cosmetic medicine” seminar. In our home mail, my mate received an invitation to learn about adding cosmetic laser treatments to his practice. The company soliciting his business was specifically directing its wares at primary care doctors.

I insisted we go for my work, and as I wandered the room during coffee breaks, I tried to understand what would bring primary care doctors to this. Most of the doctors there were unlike any I had known; to be frank, they were openly greedy. They were loving the idea of “cash on the barrel” as the salesperson put it. No insurance forms! No tricky diagnoses!

But one young gynecologist I met there – a depressed-looking woman who had been sent by the senior members of her practice – said to me in utter disgust, “I went into this profession to take care of women’s health, not to tidy up bikini lines.”

I thought about that comment the next time I had my feet up in the stirrups: What does it mean for my doctor to move from considering my health to considering my looks? The idea seemed downright creepy. Because here’s the thing: My doctor’s office is not supposed to be a place where I’m sized up for looks and sold the medical equivalent of lipstick. It’s supposed to be a place where I’m made to feel better, not made to feel wrinkly, saggy, bumpy, and spotty.

And here’s the other thing that worries me about “cosmetic medicine”: the great genius of the founding fathers was to plant a seed that said that our bodily differences should not be used to limit our social and political lives. In their own time, the Fathers bravely overturned the idea of “birthright” – of “blue blood” – being the key to power.

Later democratic American geniuses took it from there. Civil rights activists rejected the idea that skin color matters to our rights; women’s rights activists rejected the idea that sex differences matter to our rights; disability rights activists rejected the idea that needing a wheelchair means you should be barred from entering your own public schools, courts, and libraries.

So what does it mean when our doctors participate in – even sell – the regressive idea that our wrinkles, our hairlines, our breast and genital sizes should limit us? What does it mean when “free at last!” is supposedly achievable through a Botox injection and a tummy tuck? What does it mean when our doctors are saying we should, in fact, be judged by the color (or shape) of our skin, rather than the content of our characters?

I think it means “cosmetic medicine” represents a corruption of the core principles of both medicine and democracy. I think it means it is time for the medical profession to say, “Enough.” It’s time to make medicine safe for democracy, time to take back the name of the noble profession.

Really, at best, “cosmetic medicine” looks a lot more like hairdressing than health care. I’m not suggesting we let hairdressers do surgery and inject people with botulism toxin. But I am suggesting we stop gracing cosmetic procedures with the name “medicine.”

Let’s just call these practices what they are: barber surgery. That way, when one of my idealistic, smart, principled students hears that the student next to her is going into “cosmetics,” she can just answer, “Really? And here I thought we were in medical school.”

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