Ethical Implications Of Cosmetic Surgery For Aging

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PUBLICCITIZENHEALTHSIDNEY M. WOLFE, M.D., EDITORRESEARCHGROUP VOL. 18, NO. 8AUGUST 2002Ethical Implications of Cosmetic Surgery for Agingombine the aging of our population, our obsession withyouth, and our faith in technology with excesses of disposableincome for many people, and it is nosurprise that we are awash in technologic advances in the battle againstvisible signs of aging. Setting aside,for the moment, the heavily advertised, poorly-researched, and oftendownright fraudulent vitamin E, B, aminoacid-mineralantiaging concoctions, real technologic advances have occurred overthe last decade that have made it possible to erase external signs of agingpreviously considered indelible. Butwhile physicians have made the technology of "skin rejuvenation" increasingly accessible, its intrinsic valueand ethical implications have beenlargely unquestioned by the medicalcommunity. Why do we performthese procedures? What goals are wetrying to achieve? Are these goalsworthwhile? What is their impact onpatients? On medicine? On society? Asituation has developed in whichthere has been ample investigationinto what physicians can do, but farless examination of what they shoulddo. Cosmetic procedures are invasive, potentially hazardous techniques that have implications farbeyond their value as "practicebuilders." As physicians enter therealm of cosmetic surgery, they havea responsibility to explore the moraland psychosocial as well as the scientific and technical implications ofCthe procedures they perform.Let us start by examining the central question, "Why perform cosmetic surgery for aging?" If the goal ofmedical treatment is to promotehealth and healing, what is the purpose of medical procedures whereno disease exists, i.e. in performingsurgery for aging?The professional literature on theethics of cosmetic surgery, thoughdisturbingly sparse, takes one ofthree tacks, each of which is highlyquestionable. The first is that aging isa physical disease and that externalsigns of aging are de facto evidenceof illness. The second avoids theissue of aging as a physical diseaseby ascribing illness to the patient'smind rather than body. The thirdskirts the question of healing alto-gether, changing the goal of medicine from promotion of health topromotion of happiness. Each ofthese will be examined in turn.Aging as a Physical IllnessIf aging of the skin is a pathological rather than a normal, physiological process, eventual dissatisfactionwith our appearance is unavoidableand youth-promoting, cosmetic procedures are required for good health.Although the concept of aging as adisease seems peculiar to most of us,it is standard for cosmetic surgeons,who discuss the treatment of brownspots, repair of wrinkles, and correction of sagging skin as if aging werea disease which needs to be treated,repaired, or corrected. Topics suchcontinued on page 2CONTENTSProduct RecallsMay 7-July 10, 2002Tamiflu capsules, power tooth brushes and propane heatersare on our list this month . . 4Is Your Doctor Selling You to the Highest Bidder?Find out why it's important to know who is funding humanexperiments and if they're paying your doctor to recruit you . 7Hormone Replacement TherapyA recent study supports recommendations we made 11 years ago . 8Outrage of the Month"'t's Botox Night at Hopkins"Find out how Johns Hopkins planned a social event includingon the spot injections for wrinkles-and how Public Citizenhelped stop it. . . . . . . . 12VISIT HEALTH RESEARCH GROUP'S WEB SITE AT \VWW.CITIZEN.ORG/IIRG/

as the "treatment of the aging face,"are discussed with the same weightas treatment of diabetes or treatmentof tuberculosis. After all, the object oftreatment is necessarily disease; normal, physiologic processes, such asbreathing or eating, cannot be treated. By making the aging face theobject of treatment, aging is definedas a disease that requires intervention.There are both practical and theoretical problems with defining agingas an illness. Perhaps the most problematic is that, in defining aging asan illness, we implicitly define life asan illness. Aging may end withdeath, but it begins at birth. How dowe know at what point agingchanges from physiology to patholo"gy? Who is to say that puberty isacceptable, but menopause is not?Growth continues throughout ourlives on many different levels. Todemean aging by labeling it a diseaselimits our potential and underminesour humanity.Unlike plastic surgery, which corrects deformities that deviate fromthe anatomical norm, surgery for theaging face removes anatomically normal features because they trigger anegative stereotype. Every time surgeons agree to perform a facelift,they legitimize the need for thatfacelift. They confirm that lookingold is objectionable, that aging is anaberration, and that society is justified in discriminating against it. Atmedical conferences in this country,the mere presence of aging skin istantamount to an indication for cosmetic surgery. Of course, such attitudes are not unique to medicine.The cosmetic industry has made amultimillion dollar business of blurring the lines between health, beauty, and aging, portraying health andbeauty as attributes of youth whileassigning ugliness and disease to theelderly. But physicians are chargedwith protecting the health and wellbeing of their patients, and it is difficult to believe that fostering the attitude that aging skin is inherentlyoffensive is in the best interest oftheir patients.Is aging really a disease? When2 August 2002examined objectively, the properdeterminant of healthy skin is itsfunction, not its appearance. Despiteits spots and wrinkles, elderly skinfunctions remarkably well in thevast majority of individuals far intoold age. Some functional problems,such as a decline in the skin's protective barrier function, occasionallybecome clinical problems, but thecorrection of these conditions ishardly the objective of cosmetic surgery. In fact, the injury to the skinsurface incurred by laser resurfacing,chemical peeling, and other popularcosmetic techniques exacerbatesrather than ameliorates the defect inbarrier function.Aging as a Mental IllnessAs much as cosmetic surgery mayinvoke a model of disease to legitimize its place in medicine, the concept of a "cosmetic disease" is a hardsell to the public, which tends toview cosmetic procedures as frivolous, and to insurance carriers, whichWhat is the meaningof self-esteem inthe context ofcosmetic surgeryfor aging?classify them as unnecessary. Inresponse, cosmetic surgery hasincreasingly taken to promoting itselfas a cure, not for the body, but forthe mind-a sort of instant alternative to psychotherapy for aging individuals who suffer from lack of selfesteem. Perhap then, as a therapyfor psychological disease, cosmeticsurgery for aging could be a legitimate form of medical treatment.Before tackling the issue ofwhether cosmetic surgery enhancesself-esteem, a more basic questionneeds to be addressed: what is themeaning of self-esteem in the con-text. of cosmetic surgery for aging?(Though this question may seemunnecessarily pedantic, anyone inthe business of physically alteringanother human being in the name ofself-esteem had better have a prettygood idea of just what self-esteem isand what enhances it.) Althoughpride in one's appearance is certainly part of the definition, equatingself-esteem with pride somehowmisses the mark. We all know vain,self-absorbed, proud individuals whoare preoccupied with their appearance because of insecurity ratherthan self-esteem. If pride is to resultin self-esteem rather than vanity, itmust include an additional element,namely, authenticity. Any self-imageworthy of enhancement, throughcosmetic surgery or other means,must be a true reflection of who thatperson is. Enhancement of a falseself-image can result in narcissism oreven self-contempt, but it does notresult in true self-esteem.The self that benefits from cosmetic surgery is an impostor. It is builton the premise that pretending to besomething we are not builds character. Cosmetic surgeons are in thebusiness, not of enhancing who weare, but of replacing who we arewith who we or they think weshould be. Only a false self createdby the myth of agelessness can profit from surgery for aging. Only anidealized self in pursuit of perpetualyouth can benefit from procedures toerase the effects of time. There is noquestion that a false self can be bolstered by any of a number of cosmetic disguises. But how do peoplewhose worth is defined by a visionof eternal youth maintain self-esteemwith time gnawing at their heels?How do we maintain our equanimityknowing that the image we have created is a fraud? As much as we maycover, smooth, or conceal the external evidence, each day we are 24hours older and, in the end, we arewho we are. In this context, arequest for cosmetic surgery seemsmore like self-abnegation than selfesteem.The truly insidious part of nurturing an illusion is that the true self,

that vulnerable, aging human creature behind the cosmetic disguise, isneglected. There is real, physicalbeauty in all of us, whether at 20 or50 or 80. Think of photographs offamous people taken when theywere in their 70s or 80s- MotherTheresa, or Ernest Hemingway, perhaps. Would these people have benefited from "rejuvenation of theaging face?'' That kind of beauty isnot something to be peeled away.Aging and the Business ofMedicineThere is widespread recognitionon the part of many people that cosmetic surgery is not really requiredfor good health. We hear no publicoutcry when insurance companiesdeny benefits for face peels. Thereare no charitable organizations soliciting funds to provide liposuction tothe needy. Accepting for the momentthat cosmetic surgery does not treatreal disease, perhaps it is acceptablewithin the context of a businessmodel of medicine. By transformingmedicine from a profession to a business, by changing its purpose fromthe promotion of health to the promotion of happiness, surgery foraging could be viewed as a legitimate service provided by doctors tosatisfy their customers.Accepting a business model formedicine presents several problems.Whereas business operates within acontractual paradigm, which presumes negotiations among equal parties, the relationship between physicians and patients is anything butequal. The advice of physicians isimplicitly coercive. When patients aretold they need an appendectomy,they are not receiving a casual suggestion but an expert opinion thatsurgery is required for their health.Likewise, when cosmetic surgerypatients are told they would benefitfrom a face lift, they are receiving professional validation that aging is unattractive and that society is justified injudging them by their appearance.Another problem is that of scientific standards. In general medicalpractice, physicians are entrustedwith restoring patients to a normalstate of health. But unlike generalmedicine, where there are objectivestandards by which to judge thenorm, cosmetics is a matter of style.Thirty years ago, turned-up buttonnoses were all the rage; now larger,more assertive noses are in vogue.We are not talking science here; weare talking fashion. If happinessrather than health were the realobjective of medical treatment, cosmetic surgeons would be justified inetching decorative scars on their customer's faces if they fancied the patterns. Our best physicians wouldhand out amphetamines as the mostdirect way of achieving happiness.Taken to the extreme, general surgeons would be obliged to excisehealthy organs if the patientsbelieved they would be happierwithout them. The obligation ofphysicians is to make judgments toprotect their patients' health, not simply to please their customers.When happiness replaces healing' 'Editor . Sidney M. WolfeManagtng Edttor . Pbyllts McCarthyStaff Researchers . Etleen RtngelPeter LurteBenita Marcus AdlerInformation Spectaltst.john Paul FawcettProduction Mgr. . Krlsty l]acksonProofreader . Benita Marcus AdlerPrestdent . joan ClaybrookFounder . Ralph NaderI'A'I' ' '' '' IHcaltl1 LetterCopyright Health Letter, 2002Published Monthly byPublic Citizen Health Research GroupAll rights reserved. ISSN 0882-598Xas the goal of medicine, the practiceof medicine becomes a commodityand the medical profession justanother venal example of the marketculture. Cosmetic surgeons may usemedical devices and receive professional training, but they engage inthe business of selling pretty facesfor a pretty price as much as any corporate executive who promotesbeauty aids. Whereas the creation ofunnecessary markets is disagreeablewhen the inventory is consumergoods, it is far more disturbing whenthe product is surgical procedures.The inherent morbidity of the procedures, the vulnerability of thepatients, and the special privilegesgranted to physicians by society, alldemand a degree of moral conductsurpassing anything suitable for astandard business contract.Health, happiness, and beauty arenot always compatible. The peoplewho lived in Aldous Huxley's BraveNew World were all happy. Theywere all happily narcotized on drugsand wanton sexuality. They were allyoung and beautiful. They were allfree of wrinkles, of age spots, of tiredeyes, of sagging skin. But their society could hardly be called healthy.They were a population of clones, allconforming to a preapproved, sanitized ideal of beauty. Sound familiar?Mr. Huxley wrote Brave New Worldto make a point. It is time we tookanother look. Excerpts from this article werepreviously published in the Archivesof Dermatology.'The Health Research Group was co-foundedin 1971 by Ralph Nader and Sidney Wolfe inWashington, D.C. to fight for the public'shealth, and to give consumers more controlover decisions that affect their health.Material in the Health Letter may not bere-printed without permission from the Editor.Send letters and requests to HEAL1H LETfER,Editor, 1600 20th St., NW, Washington, D.C.,20009.Annual subscription price is 18.00 (12 issues). Mail subscriptions and address changesto Health Letter, Circulation Department, 160020th St., NW, Washington, D.C., 20009.Our Web site address is www.citizen.org/hrgPublic Citizen's Health Research Group Health Letter 3

Product RecallsMay 7-]uly 10, 2002This chart includes recalls from the Food and Drug Administration (FDA) Enforcement Report for drugs, dietarysupplements and medical devices, and Consumer Product Safety Commission (CPSC) recalls of consumer products.DRUGSANDDIETARYSUPPLEMENTSThe recalls noted here reflect actions taken by a firm to re bve a product from the mark t. Recalls may be conducted on a firm's own initiative, by FDA request, or by FDA order under statutory authority. A Class I recall is a situation in which there is a reasonable probability that the use of or exposure to the product will cause serious adversehealth consequences or death. Class II recalls may cause temporary or medically reversible adverse health consequences. A Class III situation is not likely to cause adverse health effects. If you have any of the drugs noted here, labelthem Do Not Use and put them in a secure place until you can return them to the place of purchase for a full refund.You can also contact the manufacturer. If you want to report an adverse drug reaction to the FDA, call (800) FDA-1088.The FDA web site is wwwfda.gov.Na111e r!f Dru, rw SujJfJielllent; Clm . '!!'Rem((; Pmhle111Lot #;Quantity anrl Di.\ lnbutum.Jlmlll}i etm·erDalyvlte Liquid, a multi-vitamin liquid packed in brown, plastic bottles, One Pint (473 mL). Product was distributed under the Hi-Techlabel; Gold line label; Class Ill; Product is contaminated with yeast, &complaints of swollen containers were receivedLot 101624 EXP 2/03; 15,413-pint bottles distributed nationwide;Hi-Tech Pharmacal Co., Inc., Amityville, New YorkDoxycycline Hyclate Capsules, 1OOmg, 500-count bottles, Rx;Class Ill; Active ingredient fails to meet test specification for relatedcompoundsLot 2985-103511 EXP 12/04; 3,601, 500-count bottles distributednationwide; lvax Pharmaceuticals, Inc., Miami, FloridaLevoxyl Tablets, 50 meg, and 100 meg, Rx; Class II; Product frommanufacturer lacks stability prior to expiration date (subpotency andsuper potency)Product codes 5297-Q, 5297-1, 5300-Q; 13,82D-100 meg tablets,18,600-50 meg tablets distributed nationwide; Allscripts HealthcareSolutions, Libertyville, IllinoisLomotll Tablets (diphenoxylate hydrochloride, 2.5 mg and atropinesulfate, .025 mg), 100 tablets, Rx only; Class II; Tablets supplied' bythe manufacturer may contain metal particlesLot Number: 021245, EXP 4/17/04; 1,288 bottles of 100 tablets distributed nationwide; G. D. Searle & Company, Chicago, Illinois.Recalled by AmeriSource Health Services Corp., Columbus, OhioLomotll Tablets, (diphenoxylate hydrochloride), Rx, bottles of 100,1,000, 2,500, and unit dose cartons of 100; Class II; Tablets may contain metal particlesLot Numbers C200511 and C200682 in 100 tablet bottles; LotNumbers C200195 and C200577 in 1,000 tablet bottles; Lot NumberC200363 in 2,500 tablet bottles; Lot Number C200360 in 100 tabletunit dose carton; 9,720 bottles and cartons distributed nationwide;Pharmacia Corp., Kalamazoo, MichiganPremarln Tablets (conjugated estrogens tablets) 0.625 mg, Rx;Class Ill; Failure to meet dissolution specificationsLot Numbers: 9001566, 9010254, 9010255, EXP 07/03, 9010509,9010510, EXP 10/03; 47,024 bottles of 100; 9,255 bottles of 1000;and 1,408 bottles of 5000 distributed nationwide; Wyeth-AyerstLaboratories, Richmond, VirginiaTamiflu Capsules (oseltamivir phosphate),75mg, 10 capsule cartons and 15 x1 capsule Professional Samples, Rx only; Class Ill;Potential cross contamination with active ingredients which couldinclude mefloquine, levodopa/benserazide, .and/or sulfamethoxazoleCartons of 10 capsules 81022-Q1, 81023-01, 81024-01, 81025-01,81025-Q2 EXP 6/02. 81029, 81029-01 EXP 9/02. Physician Samples(15s) B1025-Q3 EXP 6/02; 1,021,141 trade lots; 1,800 free goods;153,264 physician samples distributed nationwide; RocheLaboratories, Nutley, New Jersey4 August 2002

D R U G SA N DD I E T A R YName of Drug or \upplemeut; C/a.H of Recal · ProblemTri-Nasal Nasal Spray {triamcinolone acetonide), 50 meg {0.05%),120 metered sprays, 15ml bottles and professional samples, Rx;Class Ill; Subpotent, potency of the active ingredient triamcinoloneacetonide cannot be assured through labeled expiration dateMEDICALS U P P L E M E N T Scmtt.Lot #; Quautity ami Distribution; M.mmfacturerProduct code: 5050-15 and 5050-00; 377.742 distributed nationwide;Muro Pharmaceutical, Inc., Tewksbury, MassachusettsDEVICESDevice recalls are classified in a manner similar to drugs, Class I, II or III, depending on the seriousness of the risk pre. sented by leaving the device on the market. Contact the company for more information. You can also call the FDA'sDevice Recall and Notification Office at (301) 443-4190. To report a problem with a medical device, call 1-800-FDA1088. The FDA web site is http://wwwfda.gov.Name( l De1 ice;Class oj ReL·afl; Pm/Jiemlnterplak Power Plaque Remover Toothbrush; Class II; Batteriesleaking hydrogen gas during charging popping off the end capCONSUMERLot#; Quantity anti Distribution; M.muifacturerModel number 12209W; 15,758 units distributed nationwide; ConairCorp., East Windsor, New JerseyPRODUCTSContact the Consumer Product Safety Commission (CPSC) for specific instructions or return the item to the place ofpurchase for a refund. For additional information from the Consumer Product Safety Commission, call their hotline at1-800-638-2772. The CPSC

for psychological disease, cosmetic surgery for aging could be a legiti mate form of medical treatment. Before tackling the issue of whether cosmetic surgery enhances self-esteem, a more basic question needs to be addressed: what is the meaning of self-esteem in the con-text. of cosmetic surgery for aging?

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