Among the many controversies within and surrounding the field of medicine, few are as socially contentious as the surgeries presiding in one of its many subfields: elective cosmetic surgery. As part of aesthetic surgery, what makes elective cosmetic surgery (ECS) different from its reconstructive plastic surgery counterpart is its lack of restorative care and its largely physically healthy patient base.

Plastic surgery has been around for thousands of years. Like other surgical fields, the surgeries of the past were entirely focused on reconstruction or restoration of function according to the International Society of Aesthetic Plastic Surgery. It wasn’t until the early 20th century, coinciding with the rise of Hollywood and the increasing prevalence of the beauty industry, that those surgeries took on a far more cosmetic approach. Over the course of the 20th century, as mass media, consumer spending and medical innovations developed, ECSs became both popularized and normalized in society.

ECS was well established by the time the field of bioethics developed, and, as a result, the ethics of ECS have been highly debated over the years. Bioethics typically refer to the Four Pillars of Bioethics—autonomy, non-malificence, benevolence and justice—to guide decision and theory-making. Like all other bioethical discussions, ECSs create intersections between these principles, which causes ethical friction. No field of medicine is without flaw, but due to the capitalist and non-necessity nature of ECS, it generally tends to be discussed in different ways.

For example, on the surface, ECS is the epitome of the principle of autonomy. What other medical procedure could possibly compare to the degree of patient-involvement and decision making other than this purely elective care? This can be looked at as an incredibly beneficial contribution: Normalizing patients having more agency in their own medical decisions is valuable and should be encouraged. However, whatever benefit that does come from this contribution is minimized by the predatory nature of the procedures themselves. ECSs do demonstrate situations where patients take absolute authority over their own medical care, but at the cost of disrupting the balance between the physician-patient relationship. If it is normalized that the physician should be looked at as a service provider, what will that do to the sanctity of the profession itself? Will the medical field that should be focused on healing and justice shift to a marketable industry that relies on, profits from and perpetuates people’s insecurities?

Furthermore, social influence has a great impact on the decision-making of these patients, especially those in the younger age groups. Dr. Khalid Arab’s paper “Influence of Social Media on the Decision to Undergo a Cosmetic Procedure” discusses the effects of social media on cosmetic surgery using questionnaires to assess 816 participants. They found “48.5% reported being influenced by social media to consider undergoing cosmetic procedures. Respondents (51.4%) follow plastic surgeons on social media.” This indicates there is an element of coercion impeding a patient’s ability to fully consent. This study also discussed the relationship between advertisement and plastic surgery, noting how social media has “become a popular means of advertisements for cosmetic professional providers.” Not only are patients being coerced by the influence of social media, but part of that influence is coming from the medical industry itself. As if that was not concerning enough, according to Dr. Umar Rehan’s paper, “Mental health screening in facial cosmetic surgery: a narrative review of the literature,” the role of plastic surgery has a significantly greater impact on women with an almost triple the women to man ratio: “Female to male ratio [of cosmetic surgery] was found to be 2.7:1.”

This makes determining autonomy particularly challenging, in comparison to other healthcare fields, because the line between dysmorphia disorder and acceptable insecurity is dynamic and highly situational. Whatever needs “healing” is whatever the patient considers “wrong,” not what is actually causing harm or detriment to the patient’s life. With that being said, it’s just as important to recognize that the ethical issues that arise from this situation are ultimately a social issue, not necessarily a medical or individual one. While that does not diminish the bioethical responsibility of healthcare providers, it sheds light on the systematic factors that underlay every elective cosmetic surgery. The field of cosmetic surgery may not initiate the insecurities of its patient base, but it undeniably perpetuates and profits from them.