Over the past few decades, the demand and acceptance for plastic/cosmetic surgery has changed. The market for plastic surgery has exploded as the procedures become more affordable and less invasive. The general public is beginning to see this as an acceptable solution when age begins to have a visible impact on a person’s sense of physical beauty. Today, according to the Freedonia Group (2004), the US plastic surgery market is, currently, over $1 billion.
“US demand for cosmetic surgery products will grow 11.2 percent yearly through 2007, driven by new product approvals, favorable cultural and demographic trends, and improved technology. Nonsurgical products (e.g., injections, dermabrasion) will lead gains while those procedures without real alternatives (e.g., implants) remain strong.”
The obvious trend, as indicated by the abovementioned predicted growth rates, is for a strong demand of cosmetic procedures to help slow the aging process. “A recent study showed that among working women plastic surgery is the third most common reason for asking for a bank loan- behind buying a car or paying for a holiday” (Fracassini, 2000).
The recent demand increase can be partially attributed to a shift in public perception. Today, cosmetic or plastic surgery is more readily acceptable by the public. Being seen as beautiful is thought to bring rewards in terms of social acceptance, recognition, increased self-esteem, as well as other positive effects (Berscheid and Gangstead, 1982; Eagly, Ashmore, Makijani and Longo, 1991). This gradual shift in acceptance can be traced back to the early 1960’s. In 1923, the public was surprised and confused when actress Fanny Brice had a nose job as a publicity stunt (Haiken, 1997). During the 20’s, the attitude toward plastic surgery was one of nonacceptance. Four decades later in the 1960’s, when Barbara Streisand first started to gain recognition and popularity, one question frequently asked was why has she not “fixed” her nose. This question still remains unanswered today.
Once the idea of plastic surgery gained public acceptance, the concept of cosmetic surgery as a business came into play. According to the World Health Organization (1948) “health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” This definition allows the cosmetic surgery industry to regard their practice as a method to improve the mental and physical health of a patient rather than removing a flaw (Haiken, 1999).
The ability to alter a person’s appearance through surgery has been a controversial issue. Many people state that the ability to change a flawed feature to improve self-perception has a positive impact on physical and mental health. Others contend that surgical procedures are short term fixes that do not promote nor advocate lifestyle changes such as healthy eating, increased exercise and reduced sun exposure. The surgical fix often conforms to an unrealistic sense of beauty that is portrayed in the media.
The positive effect of an increase in plastic/ cosmetic surgery acceptance can be demonstrated in use of the techniques to improve self image. Plastic or cosmetic surgery
“will not change your life, it may give you greater self-confidence and add to your sense of well-being….Commonly stated good reasons for seeking cosmetic surgery include the following: "I want to do it for myself.", "I look into the mirror and I don't recognize that person.", "I feel young, I exercise, but I don't look the way I feel.", or "People keep telling me I look tired or angry" (Haines, 2005).
Many individuals are using cosmetic surgery to improve physical appearance in hopes to build confidence and self esteem. According to the America Society of Plastic Surgeons, the top five procedures in 2005 were liposuction (324,000), nose reshaping (298,000), breast augmentation (291,000) eyelid surgery (231,000), and tummy tuck (135,000). While these procedures are used to create a body that satisfies the individual, they also conform to the current societal norm of beauty.
By using medicine as a tool to improve the outward physical quality of our lives, the question of ‘when do you reach success’ often comes up for debate. Medicine is constantly evolving to utilize breakthroughs in technology which result in faster, easier, less invasive ways to improve the physical appearance. These breakthroughs often are seen by the patient as additional incentives to have a procedure. So, if technology and medicine are constantly evolving, the question that must be asked is ‘when is success reached or is success a moving target?’ According to Carl Elliott (2005),
“the end point to success becomes less clear because there is no cap on just how high our quality of life can be. We envy people whose quality of life seems better, but we have no reliable way of comparing our quality of life to theirs.”
Even though we keep raising the bar of what is considered success, is it wrong to allow an individual to seek happiness though elective plastic surgery? According to Michael Bermant (2005), “appearances and deformities are important to anyone who engages in social interaction. Teens as well as adults have valid cosmetic conditions that can benefit from plastic surgery.” Bermant goes on to say that if a procedure is done early, it can help to prevent or to reduce emotional distress.
When researching plastic surgery on the American Society of Plastic Surgeons website, some interesting patient stories can be found. The first story involved an individual who had liposuction. She had large deposits of fat that were difficult to remove through diet and exercise. When dieting in the past, she had lost weight in the ‘wrong’ part of the body and she did not want to lose any additional weight in her chest. She determined that liposuction was the best solution. Four months post-operation, she loves the new look. Recovery time was fast and pain was minimal. She is currently exercising to maintain her figure.
The second story relates the experience of a woman who had a face lift. She was unhappy with the visible signs of aging and wanted to look younger. The surgery was not painful, but she indicated that aftercare was difficult and she recommended that a healthcare professional be hired to help with the details of postoperative care. She had a lot of bruising, numbness, and swelling. Twenty days after surgery, most of her face was still numb and her jaw was tight which prevented her from eating normally. Despite the pain, the discomfort and the additional cost of hiring someone to help with the postoperative recovery period, the patient is very pleased with the results and stated that she could not have made a better decision.
These are two real life patient satisfaction stories that state the risk, the pain, and the discomfort are an acceptable necessary step in reaching happiness/satisfaction with their physical appearance. Both patients thought the procedure made an improvement to their bodies and each indicated an increase in satisfaction with their trouble body part. While cosmetic procedures can reduce emotional stress and increase personal satisfaction, is this a valid argument for enhancement surgery? It seems that the medical industry is playing into the social stigmas that exist today (Elliot, 2005). The industry has the ability to surgically enhance many physical attributes and will profit when business is strong. As society continues to create market conditions that emphasize beauty and perfection, the public uses these images as a standard for measuring their own attributes and self worth. Because an ideal is used as a standard, these individuals begin to feel inadequate and look to find a cure at any cost.
Today, public exposure to plastic and cosmetic surgery has greatly increased. Reality television shows, such as Extreme Makeover, take ordinary people and alter their appearance (Hamilton, 2004).
“By profiling ordinary people,they demystify cosmetic surgery and make it psychologicallymore accessible. Although this vicarious experience may ultimatelyresult in more sophisticated public perception, the condensedformat of the programs minimizes the risks and recovery inherentin this type of surgery. Likewise, marketing materials thatemphasize "mini" and "lunchtime" procedures also support a carefreeattitude toward elective procedures.”
“With the increasing popularity of plastic surgery, combined with the reality show Extreme Makeover, it could be easy for the general public to overlook the serious nature of elective cosmetic surgical procedures,” said Rod Rohrich, MD, president of the American Society of Plastic Surgeons (2004). “But what the public needs to know is that at the highest level of care, every surgery has risks as well as benefits.”
In the past, a psychological consult was required prior to surgery but this is no longer the case today (Hamilton, 2004). As the requirements have been greatly relaxed, it is even easier to be seen as a good candidate for surgery. The American Society for Plastic Surgery is increasing the amount of money spent on plastic surgery education through direct public marketing (Rohrich and Goldwyn, 2001). The increase in awareness has led to a greater public acceptance. According to a survey conducted by Harris Interactive (2003), surgery apprehension decreases when people are educated. Surgery is seen as more appealing when new techniques can be used to alleviate pain, anxiety, infection, and lessen the invasiveness of the procedure.
It is interesting to note that the American Society for Plastic Surgery is heavily involved in public education. This appears to be a conflict of interest in that a society which is made up of plastic surgeons is educating the public about the benefits of cosmetic surgery. Research has proven that an increase in exposure has a direct positive relationship on the number of procedures performed. Is this really education or a marketing tool disguised as public education?
The Body Miracle Makeover Show set to take place May 5-7th, 2006 in Minneapolis MN is a marketing tool aimed at the general public (The Body Miracle Makeover Show, 2006). The Show will introduce men and women to the qualified aesthetic professionals who specialize in surgical and non-surgical enhancement procedures. The show seeks to improve the public’s understanding of anti-aging procedures and provides a venue for professions to showcase their services in an environment focused on education.
As the nature of plastic surgery has shifted from reconstructive surgery to one of self improvement surgery, there have been two major movements in healthcare: an emphasis in improving the quality of life of individuals who are considered healthy and an increase in the number of medical technologies to improve physical appearance, performance, and psychological state (Elliot, 2005). Individuals see goods and services as a way to shape their identities. According to Elliot, what we own is a reflection of who we are and we measure our success through our assets and experiences. Medicine now has an additional tool to enhance a person’s appearance and improve the quality of life. The ability to improve physical appearance though plastic or cosmetic surgery has become another way in which individuals can measure success through purchase power.
According to a study on the public’s understanding of plastic, cosmetic or reconstructive surgery, the public views these terms differently in relation to the type of procedures performed but saw the expense across categories as equal (Hamilton, 2004). Cosmetic surgery is seen as short-lived, less difficult, and less painful. In addition, it is thought that cosmetic surgery requires less medical training than plastic or reconstructive surgery.
One of the major differences between elective vs. necessary surgery is the patient’s expectations related to the outcome. When an elective surgery is aesthetically based, the doctor’s and the patient’s idea of the ‘good’ outcome can be drastically different. According to Hamilton (2004), a technically perfect surgery might not meet a patients’ expected outcome due to an unrealistic expectation of the result. The physician always faces the risk of a miscommunication between the patient’s expectation and the physical limits of what can be accomplished with surgery. It is hard to properly communicate desired end results. The physician and the patient may have two very different criteria and conclusions about what is considered a successful procedure. In addition, the patient could have a difficult time verbally expressing the desired results in a detailed manner to the physician; thus, potentially resulting in a dissatisfied patient.
Hamilton (2004) suggests that a patient’s idea of cosmetic surgery to improve appearance can be better understood by relating the subject to the concept of a brand. A brand conveys a distinct concept that portrays expectations, beliefs, and quality of the product to the customer. Customers, in return, rely on the brand in order to make purchasing decisions. The business of elective cosmetic or plastic surgery is also heavily influenced by brand perception. Those seeking elective surgery are both consumers and patients who are looking for a quality product that will meet their immediate need for physical enhancement.
The importance of branding can best be demonstrated through an example. If Coca- Cola were to divide their assets into two parts: the brand and secret formula or the physical assets of the company, the greater value would exist with the brand and secret formula (Winkler, 1999). The idea of branding is just as significant in medicine as it is in the soft drink industry. Any major medical institution understands that its name and its reputation is just as important as the medicine that is practiced. An institution, physician, or a publicly traded company needs to be concerned with the public perception of what the business represents. In medicine, the brand helps the patient to establish his/her expectation and satisfaction level (Hamilton, 2004). The satisfaction level post surgery is vital to the business relationship that exists between the patient and the physician. In order to help maintain or improve satisfaction levels, physicians must account for more then just the physical well-being of the patient.
Even though it has become increasing easier to receive plastic surgery, the physician still has an ethical and medical obligation to ensure patient safety. According to Dr. William Morgan (2003), there are 49 principles that guide cosmetic surgery. The physician must not do any procedure that does not improve appearance, make any changes in which the patient is not in agreement, the procedure must have rapid recovery, the physician must know in their mind, heart and soul that this procedure is worthwhile, etc… But, according to John Jesitus (2006), there is often a fine line in deciding when to treat a patient. A surgeon must look for warning signs that the patient is not emotionally fit for surgery. These signs include but are not limited to an unrealistic expectation of body image, obsessive-compulsive behavior, and rudeness or excessive flattery.
Often, a patient with a high risk of insatiability is hard to identify (Jesitus, 2006). These individuals could potentially suffer from body dysmorphic disorder. While a physician should have a certain obligation to help these patients in a manner other then additional surgery, not all doctors have the same standards. According to the American Society for Aesthetic Plastic Surgery (ASAPS), only a hand full of physician has qualified for membership in the ASAPS. Membership is this society hold physicians to a higher standard and expressly prohibits members from giving a service in return for professional publicity. Unfortunately, it is easy for a cosmetic surgeon to misrepresent themselves to a patient. A doctor can indicate that he or she is board certified but he/she does not have to indicate which board. The patient assumes that the physician is certified by the American Board of Plastic Surgery but this is not always the case.
“Doctors strive to prolong life, and have earned some of the credit for the fact that we are living in a society that is ageing healthily as our life expectancy continues to grow. It is therefore somewhat anomalous that the public face of cosmetic surgery includes promotions which play on the insecurities associated with the superficial consequences of ageing” (Ring, 2002).
The notion that doctors are using ageing as a mechanism for increasing profits is not new (Wolf, 1990). The insecurities of patients are being exploited and used as a key marketing strategy. Ugly is broadly defined to include an ageing appearance and plastic surgeons have the magic key to reverse the process.
According to Women’s Health Queensland Wide (WHQW) (2000), the before and after photographs used in advertisements are often misleading. The photos are often enhanced to highlight the results post surgery. Facial expression, make-up, posture, fashion, etc… are used to create an exaggerated after image. The images do not give the patient any sense of recovery time and the risk associated with the procedures. In addition, many women use a standard when looking to enhance a body part. This can often be a problematic since the body make-up of each individual is different. What looks good on one individual may not look as pleasing on another. Cosmetic surgery promotes quick fixes rather then long-term life style changes. While cosmetic surgery is the only way to reduce wrinkles, the use of surgery for weight loss does not promote the need for a lifestyle change. But in defense of the procedures, a surgical procedure many be the additional boost that a patient needs for long term lifestyle change. This jump start may be the missing visual queue that results are attainable and worthwhile.
An increase in social acceptance, an increase in disposal income, new financing options and medical advances have lead to a dramatic increase in the cosmetic surgery market (Dorn). The customers are men, women, and teens who seek to improve self-image and personal satisfaction though surgery. The effects of a procedure can have both positive and negative effects on an individual. A person’s body image, self-esteem, and confidence can dramatically increased but these procedures are often not a long term solution. When a patient becomes dissatisfied again, will surgery be the reliable quick fix to slowing the aging process? While many are happy with the results of cosmetic procedures, does the ability to alter appearance to compare to a standard societal model of beauty take away from one’s own sense of self? It is clear that as society increases its acceptance level of plastic/ cosmetic surgery and the public is more informed regarding the procedures available that the usage and revenue of plastic/ cosmetic surgeons increase as well. But should a physician who has a fiduciary duty to his or her patients be able to profit from this relationship?
Business Ethic Case Questions
Should elective cosmetic services be marketed to solely promote vanity?
Do plastic surgeons have any moral obligation to discourage plastic surgery for personal vanity?
Is a plastic surgeon in the business to help patients or do they focus on the high profit margins?
Where do you draw the line in allowing additional plastic surgery?
Does the risk of surgery differ if the surgery is elective vs non-elective?
Does the plastic surgeon have a medical obligation to send a patient to counseling when the patient has a distorted self or body image?
Even though we keep raising the bar of what is considered success, it is wrong to allow an individual to seek happiness though plastic surgery?
Should a society be allowed to educate the public when the results of that education have a direct positive relationship on procedure/ revenue volume?
Does the way society depicts beauty cause dissatisfaction with your own personal body image which as lead to thoughts of cosmetic surgery?
Is a surgical procedure the right answer when personal lifestyle choice has a strong probability of reversing the results?
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