The Expectations 

Purposeful modification of the human body has been known to exist for millennia (Wieczorkowska, 2018). While the advent of modern plastic surgery is ascribed to military doctors healing soldier’s battle wounds and reconstructing bodies ravaged by war (Gilman, 1999), non restorative alterations date as far back as the 6th century BC in India where reconstruction of the nose, ears, and mouth were carried out. While in China, women’s feet were bound to achieve the ideal of small feet since the 10th century AD, more akin to modern treatments there is record of Turkish “operations of drooping eyelids” (Wieczorkowska, 2018) from the 11th century AD. And yet of recent years, there has been a noticeable shift in both the accessibility and diversity of treatment and the purposes for which they are pursued, which merits a reconsideration of our ethical relationship towards it – both as people and as medical practitioners who have a duty to guide patients past, present, and future through this new, uncharted territory. 

 

“…medical practitioners have a duty to guide patients past, present, and future through this new, uncharted territory”

THE BODY

One of the first considerations we can undertake is that despite the above mentioned historical records, for the large part of human history our bodies were considered permanent and immutable and as such, not fitting within the study of social science. But the sociology of the body has three distinct approaches, all of which are due consideration in the ethical discussion of body modification. The social regulation of the body purports that our bodies are part of a greater whole, intertwined by a social contract where we must “train” the human body into specific behaviours, respecting the social order. This can include behaviours such as wearing clothes in public, to curbing certain instincts for the general good. It’s also important to note here that while the “social order” has general universally accepted tenets, not everyone’s best interest may be considered in this structure, as many feminist movements have pointed out – especially as it pertains to bodily autonomy in relation to certain institutions. 

The lived body discusses how the outside world may affect our bodies, and in turn our sense of corporeal self. The human body, through our senses, determines the way in which one explores and responds to the world (Wieczorkowska, 2018), but likewise we may have new realizations about our sense of self when our bodies are challenged by outside factors, such as disease. This may push our relationship with our own bodies into new realms of consciousness, which may in turn create new emotional pathways between the physical and spiritual self; “somatic complaints are often accompanied by specific emotions – anger, sadness, or a sense of powerlessness” (Wieczorkowska, 2018). This physical/mental connection should be another consideration when seeking procedures that alter the body, especially in relation to how they might affect our emotional and mental state. 

The ontology of the body, or the relation of the body to the metaphysical branch of philosophy that studies concepts such as existence, being, and reality, offers the perspective that our bodies are a constant process or “project” that requires upkeep and work. Our bodies and our inner selves are inextricably connected and therefore the thinking goes that the upkeep of the body is necessary to the upkeep of the whole self. However, there can be a disconnect between the image of our corporeal selves and the reality, and aesthetic medicine often creates the image of a human being rather than simply eliminating existing defects; “that what was to contribute to the rebuilding of self-confidence creates an even greater sense of uncertainty. The boundary between the body and its image is becoming blurred” (Wieczorkowska, 2018). This phenomenon can lead to a lack of self-satisfaction when it comes to our own perception of ourselves, as well as how others’ perception of our bodies positively or negatively impact social factors such as wealth, status, and our general self-worth. 

THE CURE

With all of that in mind, the practice of aesthetic medicine can be subdivided into two broad categories: that of curative practice and that of restorative or modification. At its core, curative practice can be defined as that which “gives a chance for a normal life, restoring a healthy look and self-confidence, counteracting social exclusion and stigmatization” (Wieczorkowska, 2018), usually pursued by victims of accidents, diseases, or congenital malformations and deformities. This form of treatment might be more widely accepted as serving a greater good as it helps the disadvantaged and is inclusionary in nature. When it comes to modification or even “repairing normality” (Wieczorkowska, 2018) more ethical questions arise.

 

“When it comes to modification or even “repairing normality” , more ethical questions arise.” 

THE AGE OLD QUESTION

A study done by Anna Abelsson & Anna Willman from the Jönköping and Karlstad Universities in Sweden found that for women middle-aged or older, aesthetic injection treatments were generally sought to hide an aging appearance in an imperceptible way to others in order to maintain their social status. This affirms that in the contemporary image of the body it often appears that there is no place for old age, as it is aligned with a uselessness to society, and elderly people as a social category are marginalized and sidelined, even though in many countries they constitute a huge percentage of the population (Wieczorkowska, 2018). As a result, old age has been medicalized and treated as a disease. Moral questions arise around treating it as such. Aging is a natural process, and it could be argued that one shouldn’t fight against it. Due to the prohibitively expensive nature of many aesthetic treatments, many can’t afford to, thus further stratifying society. One could argue that a shifting of social attitudes toward aging could be a better solution in garnering a healthier body image, although this is an arguably difficult feat. Our own body image seems to be inexorably tied to sociocultural factors and the perception of others (Moulton, Gullyas, Hogg, & Power, 2018).

Considering the process of aging also brings us to the greater moral issue of the commodification of the body “with a clearly defined price and market value, depending on the investments made” (Abelsson & Willman, 2021). The state of one’s health is becoming less defined by biological circumstances and more by financial resources, which can be especially troubling as it has been shown that the value of external appearance in the labour market is being equated to knowledge and skills (Wieczorkowska, 2018). Awareness that this can create a charmed cycle of growing polarization and inequity between the rich and poor, the “improved” and the “damaged” should be a moral consideration to both patients, and especially the practitioners who are at the frontlines of this new frontier. 

“Our own body image seems to be inexorably tied to sociocultural factors and the perception of others.”

THE EXPECTATION

As leaders and practitioners of medical aesthetics, perhaps an even greater consideration is addressing unrealistic expectations, both as pertains to the physical and emotional results of a procedure. In the same study quoted above, it was found that establishing expectations clearly and realistically before the procedure resulted in the client having more satisfaction from the outcome (Abelsson & Willman, 2021). However, “when a client exhibited signs of body disorder, the risk increased that the client would not be satisfied with the treatment. An erroneous self-image was also considered possibly amplified by additional treatments and therefore clients with different forms of dysmorphic personality were denied” (Abelsson & Willman, 2021). The aim of building self-confidence through procedures can create an even greater sense of insecurity, with the inextricable mind-body connection, manipulating one often affects the other and carries a risk of psychological problems for both patients and their immediate environment (Wieczorkowska, 2018). For example, children might not recognise a new face of their parent or relative after surgery which can have serious negative consequences. 

The “standards of beauty” are also ever shifting and largely dictated by the media – both mass and social. Hitting this moving target can be challenging both as it underlines the fluidity of “self”, the instability of the self-conception, and consequent mental imbalance leading to emotional and personality disorders – and the higher probability of dissatisfaction with a procedure over time. “A client’s autonomy entails self-determination, while bioethical principles say that the treatments should be beneficial to the client” (Abelsson & Willman, 2021), but defining what constitutes as beneficial is not clear-cut; “treatments such as overflowing fish lips were denied by some medical aestheticians. What was considered fish lips or natural fullness was up to the medical aesthetician to decide, using ethical sense” (Abelsson & Willman, 2021).

“As leaders and practitioners of medical aesthetics, perhaps an even greater consideration is addressing unrealistic expectations, both as pertains to the physical and emotional results of a procedure.”

the conclusion

As can be seen, the moral and ethical parameters around medical aesthetics and bodily modification are not easily defined. While we as a society and practitioners could and arguably should consider our work in the greater context of mental and socio-spiritual health – how our work interacts, compliments or possibly works against the acceptance of the natural process of aging and the pursuit of inner harmony versus outer perceptions – history has shown that there is a fundamental connection between appearance and acceptance. We are therefore often left suspended between our own judgment and the patient’s needs. Presenting the patient with a full spectrum of consideration before treatment, including assessing their mental health as it pertains to body image, setting realistic expectations for the results of the procedure, discussing physical and psychological side-effects, the social consequences of “trendy” procedures with potentially short lived appeal, the financial consequences associated with the need to repeat some treatments, and reaching a consensus with the patient is the best way to ensure satisfaction with the treatment and to safeguard your reputation as a medical aesthetician. Education around seeking cheaper treatments performed by non-medical aestheticians is also an important step in reducing adverse effects and malpractice (Abelsson & Willman, 2021). In the fee-for-service business of aesthetic treatments, growing demand can be balanced with careful evaluation of the patient’s needs and options to ensure the best outcomes all-round. 

“…the moral and ethical parameters around medical aesthetics and bodily modification are not easily defined.”

References

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Anna Abelsson & Anna Willman (2021) Ethics and aesthetics in injection treatments with Botox and Filler, Journal of Women & Aging, 33:6, 583-595, DOI: 10.1080/08952841.2020.1730682

Magdalena Wieczorkowska (2018) Ethical dilemmas of aesthetic medicine: Between restorative medicine and the commercialisation of the body, Annales. Ethics in Economic Life 2018 Vol. 21, No. 5, Special Issue, 95–107 doi: http://dx.doi.org/10.18778/1899-2226.21.5.08 

Gilman, S. L. (1999). Making the body beautiful: A cultural history of aesthetic surgery. Princeton, NJ: Princeton University Press.

Moulton, S. J., Gullyas, C., Hogg, F. J., & Power, K. G. (2018). Psychosocial predictors of body image dissatisfaction in patients referred for NHS aesthetic surgery. Journal of Plastic, Reconstructive & Aesthetic Surgery, 71(2), 149–154. doi:10.1016/j.bjps.2017.11.004