Comment of the Day: “Three Breasted Ethics”

Alexander Cheezem contributed an informative and well-argued comment challenging my ethical conclusions in the case of “Jasmine Tridevil,” who supposedly had a surgically constructed third breast attached between her two natural ones in an effort to become a reality TV star. Her story turned out to be a scam, but the ethical analysis is still worthy of consideration. Ethics Alarms doesn’t have many medical ethics dilemmas to ponder, and it is a fascinating area. As I considered  Jasmine’s titillation, I suspected it might be a hoax, but from the standpoint of honing ethics alarms, it doesn’t matter. I’m kind of relieved, frankly.

I love the comment; I also disagree with it. More about that at the end: for now, here is Alexander’s Comment of the Day on the post, “Three Breasted Ethics”:

First off, you were indeed correct that this was a hoax (see here, for instance). You should never trust anything posted in the Daily Mail (which is very different from the Daily Mirror — and are those links to the Daily Mail’s Twitter feed and Facebook page _deliberate_?).

That said, I have to disagree with your analysis, Jack. Your argument rests on a combination of not really understanding medical ethics, a confusion of two separate ethical problems, and at least one rationalization from your own list.

To address the rationalization first, you argue by comparison to several other procedures (or, more accurately, the results of a number of procedures — Michael Jackson’s example involving God-only-knows-how-many). Their status as ethical or unethical, however, is irrelevant. More to the point, justifying the nonexistent Ms. Tridevil’s procedure as “no worse” is basically a form of what is literally the first rationalization on your list: the Golden Rationalization… although it can also be interpreted as a variant of #22 (the Comparative Virtue Excuse) or #44 (Unethical Precedent). When looked at from the standpoint of medical ethics, it can even be considered a form of #42 (If the patient doesn’t see a problem, why should we?).

At the same time, you confuse the ethics (and right/wrong) of the woman getting the procedure with the ethics of a doctor performing it.

The medical ethics issue, however, is a great deal more complex — and, frankly, I don’t have the time or energy to write an introduction to the subject as a blog comment. As such, I’ll stick to the simplest possible analysis and a very, very brief overview.

The best-known school of medical ethics is formally known as “principlism”, derived from the term “principle” and the suffix “-ism”. In brief, it attempts to treat medical ethics on the basis of several principles — four in the original formulation, although some texts involve more (or, in a few cases, fewer). Of these four principles, three — autonomy, benevolence, and nonmaleficence — are immediately relevant here (the fourth, justice, has to do with things like triage and the distribution of medical resources; I’m leaving it out for the sake of keeping length and complexity manageable).

The procedure passes — effortlessly — the test of autonomy (or respect for autonomy). If this operation were real, the surgeon was clearly respecting the hypothetical patient’s decision-making ability. She, in fact, would have sought out his assistance at great effort on her part. Obviously, there are other relevant obligations which apply (e.g. informed consent), but we see no evidence that they were left unfulfilled.

That, however, is the only such test that it would pass.

The principle of nonmaleficence is probably the best-known ethical principle in medicine, dating back to the very beginning of the Hippocratic Oath (“primum non nocere”). While colloquially stated as “do no harm”, this isn’t technically accurate in modern medical ethics: not only does the principle apply to risk, but risks and harms can actually be justified by benefit. Accordingly, a better phrasing of the concept of is that it is unethical for a doctor to perform, provide, or recommend an intervention which harms more than helps (or is clearly more harmful than alternatives).

The classic example of this is, ironically, surgery. Any surgical intervention involves substantial risk and harm — among other things, they, by definition, involve cutting the patient up… and even the most routine procedures involve not-insubstantial risk of serious complications up to and including fatality. Even if there aren’t complications, there’s a recovery period and a good bit of pain and discomfort involved.

While this is clearly justified sometimes (e.g. heart bypass surgery, extraction of precancerous tumors), there are other cases where it, well, isn’t, especially when the potential benefits are… less than tangible, shall we say? Subjecting someone to very real risk of death for a purely subjective benefit is, to put it mildly, questionable.

Because of this, the entire field of plastic/cosmetic surgery is on shaky ground at best, from the standpoint of ethics, and often derided on that basis. It doesn’t help that the field consumes medical resources and expertise for work that is almost universally without medical justification (and I’ll get back to that in a minute).

That enhancement bit you derided? That’s actually one of the dodges the field uses to try and escape this problem. In this case, we also have a pretty substantially-increased risk of buyer’s remorse… and this sort of thing is nowhere near easily reversible (see the mention of the not unsubstantial risk of morbidity above).

And, of course, the usual methods the field uses to try and escape this problem just don’t work in this (hypothetical) case.

Finally, we get into the principle of benevolence. As I’ve noted before, the benefits of this sort of operation are rather intangible (even if the breast in question has a good bit of heft to it) in comparison to the risks and harms. This is especially true when any woman who wants to turn off men has far, far simpler options available to her than acquiring a new breast (and, frankly, I’m not sure that the third breast strategy would be noticeably effective given some of the men out there).

But, more to the point, this is about medical benevolence, and medicine itself has a rather strict formal definition: It’s the art and science of the prevention and treatment of disease (with “disease” having a technical definition which is very much different from how the word is used colloquially: injuries and the like fall under its umbrella, for instance).

Or, to put it another way, there is no potential medical benefit whatsoever from this procedure. The same can be said about most cosmetic procedures, of course, but this is far more extensive and far more risky than almost any genuine cosmetic procedure I’ve heard of… including, notably, the examples you provided.

So… yeah. I have to disagree with your analysis. It’s 0 for 3 in even the most basic test… and so yes, a good bit of outrage is justified from a doctor who hears about it and thinks it’s genuine.

Anyway, sorry for the delay in getting this posted. It was worked on in my spare time, such as it is, over pretty much the entire time since you posted this.

I’m back. As I noted in my response to the comment in its original setting,

The crux of your point, I think, is this: “the entire field of plastic/cosmetic surgery is on shaky ground at best, from the standpoint of ethics.” The last time I wrote on this topic, regarding the women who got the cartoon lips, many of the comments compared the plastic surgeon to a tattoo artist. I think that’s a an apt comparison in this case. The question is whether human beings have a right to look like they want to, including like freaks, and whether the ethics of MEDICINE apply, or should apply. I think I accurately judged this plastic surgeon by a reasonable reading of his field’s own Code.

I’ll begin by stipulating that my opinions regarding medical ethics are biased two ways: 1) I think doctors too often play fast and loose with their own ethical codes, interpreting them to mean what is most convenient for a particular case (and fee), and  2) my view of professional ethics is skewed to the legal ethics perspective, in which the client, not the lawyer, calls the shots—determines the objectives, agrees (in most cases) with the means of achieving them, and doesn’t have his or or motives subordinated to the lawyer’s conscience.

The entire field of “cosmetic surgery” is, under Alexander’s strict principles, unethical except when the objective is to treat a deformity or an injury, unless it is the–to quote his comment—“purely subjective benefit” of the patient. Like, say, nose jobs? Who but Jennifer Grey thought the adorable “Baby” of “Dirty Dancing”

DirtyDancing_071Pyxurz

had to be transformed into whoever this generic unremarkable beauty is…

main-jennifer-grey.

..? And was it a doctor’s responsibility to say, “No, you don’t want to look like that?” Or in this case, in which a lovely women with a human figure wanted to go from this..

Pam-Anderson-Before-Surgery

..to this…

Pamela_Anderson

...? That surgically enhanced Jessica Rabbit figure took Pamela Anderson out of the generic Hollywood cookie-cutter blonde category and made her a Baywatch Babe, a pin-up, and a millionaire. Should a doctor have refused to help her with her plan, arguing that there are far simpler options available to her”—like, say, taking acting lessons—to achieve success than pumping herself up like a balloon? He can advise her, certainly, but it’s her career, her plan, and her body.

Wait…where have I heard that before? Doctors maintain that abortions are ethical (we know they are legal), even when a young woman wants one to make sure she can fir into all of her cutest outfits, and even though it involves “harm” to a human organism with separate DNA and a heartbeat. The justification is that it is the woman’s choice, not the doctor’s. Why do the vague principles of nonmaleficence and benevolence not trump autonomy is these cases—especially in cases of late term abortions—when they are deemed sufficient for a doctor to dictate to a woman what is appropriate to do to her body when only one human being—her—is involved? Who is the doctor to say that this is a stupid way to become a reality show star, and that the risks outweigh the benefits?

I think the medical ethics argument is merely the “ick factor” in disguise. We are used to vain and needless nose jobs, absurd breast enhancements, and abortion on demand so they are not seen as sufficiently malign to justify substituting  the doctor’s sense of right and wrong for the patient’s. Letting a patient who wants to do so look like this…

Giant breasts

or this…

Human+Barbie

…is just wrong. No, it’s stupid, it’s weird, it’s a risk I wouldn’t take—but doctors, much as they would like us to believe otherwise, aren’t gods, and have no business telling us what is in our own best interests, as long as it is legal. If they don’t want to do the surgery, fine: my hat’s off to them. But when it comes down to matters of taste and personal dominion over one’s own body, autonomy should rule. “Harm” can be by by its very nature subjective. If the person being harmed understands the alleged harm, doesn’t regard it as harm, and nobody else is harmed, then it’s not harm, no matter what the doctor or any of us  think.

The medical profession needs to focus more honestly on the “beneficence” of abortion before I’m inclined to take the claim that helping women turn themselves into freaks for fun, fame and profit is a breach of medical ethics.

15 thoughts on “Comment of the Day: “Three Breasted Ethics”

  1. While it will leave a bit of disconnect, given the differences between your commentary here and in the original post, I will quote my reply there:

    “Well, you’re certainly proving my points here regarding your analysis. Drawing analogies between legal and medical ethics simply doesn’t work, for the simple reason that legal and medical professionals have very different jobs, meaning that they take very, very different roles in regards to their clients/patients.

    “And yes, the risks and harm in this case is every bit as clear as I made it seem — more so, actually, as I was recently reminded when a mentor and dear friend failed to survive what should have been a routine operation. The hypothetical third breast would be anything but routine, and would actually involve a number of very substantial medical risks depending on the exact details of how the operation was carried out.

    “That said, you’re still confusing two very separate ethics issues. I have no problem, ethically speaking, with a woman getting such a procedure (at least in the abstract). I have issues with a doctor performing it. By analogy to legal ethics (which, as I mentioned, doesn’t fully work), this is akin to the difference between a person representing themselves in court and a lawyer suggesting that they do so.

    “But, well, autonomy trumps in law. It doesn’t in medicine. It can’t. Doctors override autonomy all the time. They have to. This ranges from the simple and clearly justified (e.g. vaccinating a child who doesn’t want a needle in the arm, triage in disaster situations) to the more controversial (the lack of a true standard for competence and capacity to give informed consent leads to many such cases, for instance, as do the numerous cases of psychiatric and psychological interventions surrounding suicide). In fact, one of the most influential medical ethics textbooks (Beauchamp & Childress’s Principles of Medical Ethics, which I’ve been paging through as I write this) contains a detailed discussion of when “interventions intended to mitigate harm to or to benefit a person, despite the fact that the person’s risky choices and actions are informed, voluntary, and autonomous” (p. 217 in the seventh edition) are justified.

    “A notable quote: “physicians do not have a moral obligation to carry out their patents’ wishes when they are incompatible with acceptable standards of medical practice or are against physicians’ conscience.” (Beauchamp & Childress, p. 226). This is a clear case of the former.

    “As for the ethics of medicine applying? Well… yes, they do. How and where they do is perhaps a matter of debate, but the anesthesiologist’s job is largely to keep the patient from dying during the operation, and a great deal of the personnel involved have similar duties.

    “And then we get into the justice issues (e.g. we are having a major shortage of several anesthetics) which complicate things further.”

    Here, I will add a few things:

    — The harms I was referring to did not include the presence of a third breast. They were the recovery time (which isn’t that much of an issue) and the not-insubstantial risk of complications up to and including fatality (which, well, are).
    — I explicitly stated that these weren’t “strict principles” in the sense that you were talking about: I was deliberately using an simplest analysis I could as a framework in order to illustrate the problems while keeping the length of my post manageably brief… and said so.
    — Bringing abortion into this in this manner is another example of one of the rationalizations on your list: #22, the comparative virtue excuse. Yes, there are problems in the medical field, and cases where things are done for silly reasons. That has no bearings on the ethics of this hypothetical case.

    • “this is akin to the difference between a person representing themselves in court and a lawyer suggesting that they do so.”

      That’s pretty much it in a nutshell.

      Is Jack arguing that if the canon of medical ethics renders a physician “incapable” of providing a treatment requested, the legal philosophy of personal autonomy should trump medical ethics; at least until the code of medical ethics changes its ruling on abortions?

      • “That said, you’re still confusing two very separate ethics issues. I have no problem, ethically speaking, with a woman getting such a procedure (at least in the abstract). I have issues with a doctor performing it. By analogy to legal ethics (which, as I mentioned, doesn’t fully work), this is akin to the difference between a person representing themselves in court and a lawyer suggesting that they do so.”

        No, it’s not. It is akin to a client wanting to take on an expensive, long-shot lawsuit with some chance of success if the court crafts new territory, and a lawyer agreeing to try it, after 50 other lawyers have refused. And the lawyer IS ethically permitted to go ahead and handle the risky case, as long as he properly informs the client why he thinks its a bad idea. Doctors allow patients to choose risky or experimental treatments with minimal odds of success, when the patient’s life is at risk. Who is a doctor to question a woman’s conclusion that her life will only have value with size MM breasts, a face like doll, or three breasts? She might be right. Only she can know.

        • No, Jack — that’s a pretty blatantly inaccurate analogy. It’d only be at all analogous if the lawsuit was outside the scope of what’s considered acceptable legal practice.

          Also, doctors don’t just allow patients to choose risky or experimental treatments when their lives are on the line — they recommend and provide them. The ethics of the latter are complicated and, frankly, not something I have time or space to discuss here, but the justifications of the former are generally really damned simple: risky treatments are generally also desperate ones, and have appropriate medical justification.

          It’s actually ironic that you mention experimental treatments, by the way, since the hypothetical third-breast operation would qualify as one… except, of course, for the fact that it lacks any medical justification whatsoever.

          That said, what doctors allow isn’t the point here, nor is their opinion of a woman’s conclusion about her life’s value. The issue is about what services a doctor can ethically provide.

          • 1.A lawsuit like the one I described is exactly that, which would be the only reason 50 lawyers could ethically turn it down….because it was outside the range that the profession regarded as a legitimate, non-frivolous lawsuit.
            2.No, Alexander, it’s what doctors SAY they can ethically provide. Doctors have a deity complex, and this version of “harm” expresses it.
            3.What is harm? Is it objective or subjective? Harm to whom? What factors are balanced? The cases where a patient believes that a limb is an alien, and wants it removed are also on point: is removing it if that’s the only way the patient will have psychic peace harm, or remedy?

            Your argument comes down to a paternizing “now, now, we know best.” I don’t concede that any profession absolutely knows best when considering their own profession’s ethics. They are in a bubble.

            To some small extent I’m playing devil’s advocate here—I wouldn’t do the third breast operation, because I think it does constitute harm. But I still think the profession pretends it has a clear standard when it doesn’t.

    • Nope. You are changing your argument. You specifically challenged the benefit sought by the patient on the grounds that it was subjective, or “Doctor knows best.” That is required if you are going to reject the operation on a risks/benefits basis. I’m saying that the doctor is not the one who can rate the benefits, only the risks. I’m saying that your argument wipes out virtually all cosmetic surgery based on medical ethics principles, and frankly, that’s fine with me, but be honest about it. Purely cosmetic purposes are not worth the risk of surgery, period….is that the message? Got it, and that makes sense. What doesn’t make sense is for the doctor to anoint himself as arbiter of what is “necessary” or “benificent” cosmetic surgery based on personal taste. A patient should be able to say, if she is of sound mind, “I am willing to accept these risks in order to be made a freak.” A doctor should be able to say, “Not by me, you’re not.” But if she is willing and informed and the only one at risk, there should be nothing unethical about him going ahead…if he chooses.

      And you are misapplying Rationalization #22. I’m not saying that you should do three breast surgery because it’s not as bad as late term abortions. I’m saying that a profession that says late term abortions are ethical because a woman has dominion over her own body but getting three breasts are not because—ICK!_—is hypocritical, and making up the rules as it goes along.

      A lawyer CAN’T provide a client legal services when that client wants something that is illegal,l frivolous, or an abuse of process, and has a right to withdraw if what the client wants is imprudent or repugnant. But doing the latter is a personal choice, not mandated by the rules. As it should be here.

  2. There is nothing better than reading two clearly articulated points of view on a matter.

    What no one has addressed is the legal liability for the surgeon that performs the surgery when the risks are explained to a patient, with dominion over his/her body, and who later believes to have suffered bodily injury or emotional distress because of the patient’s choice, when no negligence by the doctor occurs other than to agree to perform the surgery.

  3. Since when are legal ethics and medical ethics interchangeable? Codes of ethics are derived from the analysis of duties between parties. The duty of a physician towards his patient is nowhere near the same as the duty of a lawyer to his client. Not even close.

    The code of medical ethics says that physicians and nurses must not participate in state executions of prisoners. Care to argue that a physician practicing in a state with capital punishment can be ordered to participate in said executions; as if it were jury duty?

    “I’m saying that a profession that says late term abortions are ethical because a woman has dominion over her own body but getting three breasts are not because—ICK!_—is hypocritical, and making up the rules as it goes along.”

    Tu quoque (appeal to hypocrisy) is not a valid argument Jack; it’s an informal fallacy.

    A chain-smoking oncologist ordering me not to smoke because smoking causes cancer is not wrong because he’s a hypocrite.

      • He did make the hypocrisy of Scot Glasberg a large portion of his argument. Nonetheless, how is hypocrisy proof that medical ethics are fabricated on the fly?

    • All over the map:

      1. Ethical principles are ethical principles. Professions give them different priorities. That doesn’t mean they are unrelated.

      2. No, I care to argue that applying “do no harm’ as it relates to a lawful execution is exactly the kind of integrity deficit in medical ethics I’m referring to. And yes, the law can order a professional to do something unethical under that profession’s code of ethics—why do you think journalists go to jail when they are ordered to give up sources?

      3. Terrible analogy, via the oncologist. The issue is that the medical profession’s supposed ethics code (there is no single or accepted one, you know) is vague enough that it serves whatever agendas the medical profession feels like serving. I might question the judgment of the chain-smoking oncologist, but not his ethics…and what you described isn’t even hypocrisy.

      • I said: “Since when are legal ethics and medical ethics interchangeable? Codes of ethics are derived from the analysis of duties between parties. The duty of a physician towards his patient is nowhere near the same as the duty of a lawyer to his client. Not even close.”

        You said: “Ethical principles are ethical principles. Professions give them different priorities. That doesn’t mean they are unrelated.”

        I’ll grant that medical ethics and legal ethics are related in that they’re both called “ethics”; much like consequentialism and deontology are not “unrelated.” Otherwise you completely ignored what I said.

        I said: “The code of medical ethics says that physicians and nurses must not participate in state executions of prisoners. Care to argue that a physician practicing in a state with capital punishment can be ordered to participate in said executions; as if it were jury duty?

        You said: “No, I care to argue that applying “do no harm’ as it relates to a lawful execution is exactly the kind of integrity deficit in medical ethics I’m referring to.”

        The AMA rules regarding physician participation in executions are very clear; thereby making it very difficult for a state to find physicians willing to break those rules; much less admit to doing so on record. (See When Law and Ethics Collide — Why Physicians Participate in Executions, by Atul Gawande, M.D., M.P.H.)

        The few ANONYMOUS physicians that do participate in executions create no more of an “integrity deficit” in the AMA code of ethics than lawyers who commingle their clients funds create an “integrity deficit” in the code of legal ethics they broke in doing so.

        You said: “And yes, the law can order a professional to do something unethical under that profession’s code of ethics—why do you think journalists go to jail when they are ordered to give up sources?”

        Having already stated that the duties of a physician to a patient are nowhere near the same as a lawyer to his client, I asked a specific question regarding the court’s willingness to order physicians to break with the code of medical ethics. Rather than answer my question, you answered your own question; intentionally avoiding my point.

        A journalist’s code of ethics, like a lawyer’s code of ethics, doesn’t even resemble a physician’s code of ethics. Since the law is not a physician it tends to give great deference to the guidance offered by actual doctors. That’s why I asked you the question I did; and that’s why your comment about reporters was non-responsive.

        Has any court ever VALIDLY ordered a physician to treat a patient in a manner that blatantly violated of the AMA code of ethics? If so, I’d love to read about it since simply attempting to force a physician to treat “violent or intransigent patients” has been shown to raise 13th amendment concerns.

        See When Doctor’s Slam The Door By Sandeep Jauhar, M.D.
        Published: March 16, 2003 http://www.nytimes.com/2003/03/16/magazine/when-doctor-s-slam-the-door.html?pagewanted=all

        Finally, the Tu quoque example I provided was textbook appeal to hypocrisy.

        From *ttp://rationalwiki(dot)org/wiki/Tu_quoque

        Tu quoque (“You too!” — pronounced “too kwoh-kway”), also known as appeal to hypocrisy, is a form of ad hominem fallacy that occurs when it is assumed that an argument is wrong if the source making the claim has itself spoken or acted in a way inconsistent with it. The fallacy focuses on the perceived hypocrisy of the opponent rather than the merits of their argument.

        Tu quoque in response to criticism

        The first common variant of the fallacy is the “you criticize X, but you use something related to X” argument:

        Bob: “Smoking and alcoholism are well-known risk factors for cancer.”

        Alice: “But you yourself smoke and drink a lot! You’re wrong!”

        The fact that Bob is a smoker and drinker doesn’t mean that he is wrong about the effects of those habits….

        • Going backwards:

          1. Wrong. And don’t explain to me about the hypocrisy fallacy—I have written about it here often. You are the one misusing it. “I’m saying that a profession that says late term abortions are ethical because a woman has dominion over her own body but getting three breasts are not because—ICK!_—is hypocritical, and making up the rules as it goes along.” That is the statement you are referring to. I did not cite it to show that doctors are wrong about a women having dominion over her own body. I cited it to show that doctors don’t really believe that….they just say it when it is useful. Get the distinction?

          2.”Has any court ever VALIDLY ordered a physician to treat a patient in a manner that blatantly violated of the AMA code of ethics?” Speaking of argument fallacies: you are laying a “No True Scotsman trap”—if I point out an example, you will say, “but I Said VALID>” The fact is that nothing stops any court from ordering a lawyer, a doctor or a journalist to violate their Ethics Code. Such Codes aren’t laws, most of the time.

          3. You seem confused about what professional Codes are. They are often self-serving, and designed as much to protect the professionals as to ensure ethical conduct. The bodies themselves make the rules burdened by conflicts of interest. That is why I teach legal ethics, not Professional Responsibility (that is, the legal rules). Sometimes following the rules is unethical. Often, in fact.

          4. “The AMA rules regarding physician participation in executions are very clear; thereby making it very difficult for a state to find physicians willing to break those rules; much less admit to doing so on record. (See When Law and Ethics Collide — Why Physicians Participate in Executions, by Atul Gawande, M.D., M.P.H.)” You do understand the difference between rules and ethics, right? So the AMA, when it was dominated by anti-capital punishment advocates, made a rule to make lethal injections harder. This was politics, not ethics. The AMA’s rules are guidelines for ethics as the body wants them to be at a moment in time…that does not preclude me or anyone else from pointing out, accurately. that a result endorsed by a rule is still unethical.

          5. “I’ll grant that medical ethics and legal ethics are related in that they’re both called “ethics”; much like consequentialism and deontology are not “unrelated.” Otherwise you completely ignored what I said.” Gibberish. All ethical Codes are built from the same values, virtues and principles. Professions define themselves by ranking them differently and resolving ethical conflicts differently. In this case, we are talking about whether “harm” should be the call of the individual who will suffer the alleged harm, or a doctor. Naturally, doctors, being the ones who make their ethics rules, say the latter. because they write the rule this way doesn’t make it correct, or ethical.

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