Chapter 3:
Ethical Considerations

The right to search for truth implies also a duty, one must not conceal any part of what one has recognized to be true.

Albert Einstein

Cosmetic surgery is judged on its aesthetic merits and the patient’s ultimate satisfaction, not on the speed by which it is accomplished. Cosmetic procedures must also be judged by ethical criteria. Because of the elective and purely cosmetic nature of liposuction, significant surgical risks are unreasonable, and it is unethical to subject a patient to unknown or unnecessary surgical risks. Convenience or financial considerations should not compromise patient safety.

Ethics is an important aspect of cosmetic surgery. Physicians are confronted daily with ethical issues. Cultivating moral behavior within professional groups requires that decisions involving ethics be identified and candidly discussed. The ethical ramifications of everyday decisions are often subtle or obscured by a lack of awareness. Financial conflicts of interest and inappropriate professional behavior in “turf warfare” are two obvious examples of ethical issues that directly affect patients’ welfare. Whether to inform an anxious patient about the risk of death from anesthesia and whether to offer local anesthesia or the “speedier general anesthesia” are more subtle examples.¹

Do No Harm: Specific Issues

Tumescent liposuction has become the most popular, and possibly the most lucrative, cosmetic surgical procedure in the world. Whenever physicians’ personal financial concerns are intertwined with patients’ health care decisions, the potential for an ethical conflict of interest cannot be ignored. Ethics and professional decorum must be central to every liposuction surgeon’s commitment to maintain the highest standard of care.

Ethics is a complex subject with many facets and profound dilemmas.^2,3 In its simplest terms, ethics is about vulnerability and potential harm. We are all vulnerable, and therefore ethics is a concern for everyone. Causing harm to someone is unethical when the harm is unnecessary. Thus the motivation behind an action that harms someone is an important determinant in judging the ethics of the action. Was the action unnecessary, preventable, or intentional? Was it the result of negligence, ignorance, or wrong beliefs (blind obeisance to dogma)?

No mystery or subtlety surrounds the main tenet of medical ethics: benevolence, or do no harm.

Criteria for assessing the relative merits of an action have evolved over the centuries. In the 1700s, Emanuel Kant held that intention is most important in appraising the ethical merits of an action. In the 1800s, Jeremy Bentham and John Stuart Mill were utilitarians who shared the view that human action should be assessed in terms of its production of maximum value; in other words, the greatest good for the greatest number. They believed that consequences of a person’s actions are more important than the person’s intentions. In the 1900s, multiculturalism recognized that good is defined relative to a cultural perspective. Respecting differences of perspective is important. For example, different surgical specialties have different cultures and different perspectives.

Choice of Anesthesia

A sibi-placebo (“to please oneself”) is a treatment that a physician prescribes because it is convenient, not because it is best for the patient. General anesthesia is a sibi-placebo when it is used merely for the surgeon’s convenience, not because it is necessary.

When given a choice between local and heavy IV sedation or general anesthesia, most patients choose local anesthesia. Most surgeons also prefer local anesthesia for themselves when having cosmetic surgery. In a survey of plastic surgeons who previously had cosmetic surgery, 90% had chosen to have local anesthesia.⁴ In contrast, among the patients of these same surgeons, only 40% received local anesthesia for their cosmetic procedures.

This raises the following two questions:

1.         How often is general anesthesia used as a sibi-placebo?

2.         To what extent do surgeons provide fully informed consent to their patients with regard to choice of anesthesia?

On the other hand, local anesthesia is not appropriate for all patients. A small percentage are unable to tolerate any surgery under local anesthesia. Such patients should be offered general anesthesia together with information about its risks and benefits.

Conflicts of Interest

Fraud and cheating of insurance companies are obvious forms of unethical behavior. It is unethical to bill insurers for an elective procedure that is principally motivated by cosmetic concerns.

Conflict of interest is a particular type of ethical dilemma and occurs when an individual or a group is motivated by conflicting goals, such as service to the public and a self-serving hidden agenda that is not in the public’s best interest. Physicians, both individually and as a group, are subject to the principles of medical ethics.⁵ In medicine the utilitarian view of ethics maintains that an action should be judged in terms of what is best for the patient.

Financial conflict of interest is well recognized as being unethical. For example, if a procedure with local anesthesia is safer and more comfortable for patients, but a surgeon believes that general anesthesia is more time efficient, or an anesthesiologist recognizes that general anesthesia is more remunerative, a possible financial conflict of interest exists.

Editorial conflict of interest in peer review and publication in medical journals occurs when a reviewer or editor is associated with activities that could inappropriately influence judgment, regardless of whether that judgment is directly affected. Promoting high ethical standards and avoiding conflict of interest currently are major topics of discussion among medical journal editors.^6-9

Intellectual conflict of interest is more elusive and occurs when one’s ethical judgment is influenced by the possibility of personal recognition, career advancement, increased power, or enhanced prestige for oneself or one’s group. Real and potential intellectual conflicts of interest are pervasive in science and medicine.¹⁰

Compromising one’s academic honesty in favor of satisfying intense peer pressure to conform to political dogma is an intellectual conflict of interest.

Misinterpretation of Technique

In 1995 the ABC television program “20/20” presented the tumescent technique as it was intended to be used: totally by local anesthesia. Hugh Downs declared it to be safe. It became so popular that patients simply would not consider liposuction by any other technique.

After viewing “20/20,” prospective patients naturally asked surgeons if they performed tumescent liposuction. If surgeons did not know how to do tumescent liposuction totally by local anesthesia, they might compensate by saying they did “a modified version of tumescent liposuction” using systemic anesthesia together with the elimination of blood loss provided by the tumescent technique. Patients often misinterpret such an answer and assume that liposuction with systemic anesthesia is as safe as liposuction totally by local anesthesia. Encouraging such a misconception is disingenuous and an unethical conflict of interest.

Surgeons may exploit the combination of tumescent hemostasis plus systemic anesthesia to remove excessive volumes of fat during a single liposuction surgery. The danger of such excessive surgical trauma is rarely explained to prospective patients. In this sense, patients are deceived when led to believe that liposuction under systemic anesthesia with tumescent infiltration for hemostasis is as safe as liposuction totally by local anesthesia.

The safety of tumescent liposuction is based on (1) avoidance of the risks of general anesthesia, (2) elimination of bleeding, and (3) elimination of intravenous fluids. Surgeons who claim to do tumescent liposuction but use general anesthesia are misleading patients.

Patients and the media have failed to recognize the distinction between tumescent liposuction totally by local anesthesia and tumescent liposuction with systemic anesthesia. In essence, two definitions and two standards of care have evolved (see Chapter 2).

Withholding of Knowledge

Inhibiting the exchange of ideas between specialties is the antithesis of academic freedom. Anything that impedes communication or fosters enmity between specialties is not in patients’ best interests. It is an intellectual conflict of interest. Patients are harmed to the extent that some surgeons are unaware of higher standards of care that might exist outside their particular professional group.

The rationalization that any specialty is justified in hoarding knowledge because other specialties are not trained to use such knowledge safely is a potential conflict of interest. To the extent that the particular specialty believes that it stands to gain financially by not sharing knowledge with competitors, to the potential detriment to patients, a financial conflict of interest exists.

Dermatologists have debated the ethics of restricting the participation of another specialty in dermatologic education. The main focus has been on whether or not dermatologists should teach dermatologic therapy to primary care physicians. In a symposium on ethics with audience participation during the 1994 annual meeting of the American Academy of Dermatology, more than 90% of the voters thought that withholding knowledge was unethical.¹¹ Where patients’ health is concerned, a more knowledgeable physician or surgeon clearly is in patients’ best interest. A self-serving financial motive for withholding knowledge would be unethical.

Dermatologists should teach other specialties how to do liposuction more safely and with better aesthetic results using the true tumescent technique.

Competition

The American Medical Association (AMA) encourages competition among physicians based on quality of service, skill, experience, and safety. Ethical medical practice thrives best under free-market conditions, when prospective patients have adequate unbiased information and opportunity to choose freely between and among competing physicians.⁵

Competing medical specialties, as with nations, can interact with comity or enmity. Publicly maligning the competition is not ethical. It is considered unethical to denigrate the reputation of a colleague or the credentials of a competing medical specialty.¹² The Council of Medical Specialty Societies has passed a resolution condemning such behavior.

Surgeons have not made a “good faith” effort to obtain sound epidemiologic data that would support any particular specialty’s claims of greater safety or superior surgical skills. Deceptive and misleading claims of superiority are unethical. When surgeons make public statements claiming that patients should choose only a surgeon certified by their specialty, they imply “a prediction of future success or guarantees that satisfaction or a cure will result from the performance of the member’s services.”¹³ To the extent that such public proclamations “appeal primarily to a lay person’s fears, anxieties or emotional vulnerabilities,” it is unethical.

It is reasonable to ask, “Which specialty has had the greatest incidence of deaths associated with liposuction and greatest incidence of unplanned hospitalizations after liposuction?” Without a sincere effort to study the epidemiology of liposuction-associated deaths, any surgical specialty’s claim that it has superior training is hypocrisy. To ignore surgeons’ affirmative responsibility to pursue actively such an epidemiologic study is an ethical conflict of interest.

Unethical Advertising

Advertising that is misleading is unethical. For example, it is deceptive to show a “before photograph” with an “after photograph” that encompasses multiple cosmetic procedures, while stating or implying that only one procedure was done. Other aspects of ethics and advertising are more subtle. For example, it would be unethical to accuse a competitor of false advertising irresponsibly. One must be sure of the facts. A statement that is actually true might appear to be false to a naive surgeon from one specialty who has not kept up with state of the art or the literature of another specialty.

A public relations campaign implying that certain cosmetic surgical procedures should be performed only by surgeons certified by a particular board is viewed by other specialties as undignified, offensive, and unethical. The claim that any group of surgeons is better trained to do cosmetic surgery is a meretricious argument; it is plausible but specious. Self-serving claims of clinical superiority, unsubstantiated by objective data, transform “medical ethics” into an oxymoron. The intensity of belief in the superiority of one’s own training is not a measure of the validity of such beliefs.

Liposuction advertising is particularly prone to exaggerated and misleading claims of experience and expertise. For example, an advertisement that claims that the surgeon has done “more than 3000 procedures” implies that the surgeon has treated more than 3000 patients. If the surgeon has merely done liposuction on multiple areas of only 400 patients, the advertisement is deceptive and unethical.

Healthy Competition

Unethical behavior between competing specialties cannot be dismissed as simply a manifestation of “turf warfare.” Calling attention to unethical conduct and conflict of interest is the essence of professional behavior and editorial responsibility.

Competition between individual or groups of surgeons in the arena of cosmetic surgery is in patients’ best interests. Surgeons should strive to provide patients with the best cosmetic results, the safest anesthetic technique, the most comprehensive information, and the most respectful and dignified care. In the interest of optimal patient care, surgeons should share their knowledge with one another. As professionals, they should strive to win through positivity. Journal editors, leaders of professional societies, and individual surgeons should actively promote ethical competition and eschew negativity and denigration of competitors.

Summary

Each medical specialty has its own unique cultural view of the world. Surgical training is analogous to religious education. It inculcates belief in clinical dogma and nurtures a deep faith in the fundamental truthfulness of instruction. Understandably, therefore, a group of specialists might disregard an intellectual conflict of interest in a debate with a competing specialty. The multicultural concepts of twenty-first-century ethics, however, demand great tolerance among different surgical and medical specialties.

References

1. Waisel DB, Truog RD: An introduction to ethics, Anesthesiology 87:411-417, 1997.
2. Beauchamp TL, Childress JF: Principles of biomedical ethics, ed 4, New York, 1994, Oxford University Press.
3. Thiroux J: Ethics theory and practice, ed 5, Englewood Cliffs, NJ, 1995, Prentice-  Hall.
4. Cohen K: Lecture delivered at the Cambridge Cosmetic Surgery Conference,           Cambridge, England, 1994.
5. American Medical Association: Code of medical ethics: current opinions of the     Council on Ethical and Judicial Affairs, Chicago, 1992, The Association.
6. Riis P: New paradigms in journalology, J Intern Med 232: 207-213, 1992.
7. Caelleigh AS: Credit and responsibility in authorship, Acad Med 66:676-677, 1991 (editorial).
8. Constantian MB: On the genesis and spread of ideas, Plast Reconstr Surg 86:1174-1175, 1990 (editorial).
9. International Committee of Medical Journal Editors: Conflict of interest, Ann Intern Med 118:646-647, 1993.
10. Marshall E: When does intellectual passion become conflict of interest? Science 257:620-624, 1992.
11. Real-life ethics: how practicing dermatologists view potential conflicts of interest, Dermatol World, November 1994, p 14.
12. American Academy of Dermatology Ethics Committee: Ethics in medical practice: with special reference to dermatology, Schaumburg, Ill, 1993, The Academy.
13. American Society of Plastic and Reconstructive Surgeons: Code of ethics, Arlington Heights, Ill, 1994, The Society.