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