The Ethics of Cosmetic Surgery
Discussions of the ethics of cosmetic surgery tend to focus on whether cosmetic surgery is something that is morally justified. Some argue that cosmetic surgery is never acceptable, for a host of reasons. For example, that cosmetic surgery is always to improve the appearance and therefore feeds vices such as vanity; that cosmetic surgery takes time away from more important pursuits; or that surgery is only practiced on certain groups, for example women, marking the group as inferior and resulting in subordination.[i] Others argue that cosmetic surgery is always permissible, simply a matter of choice, and that informed preferences should always be respected. Still others argue that cosmetic surgery is acceptable in some instances, but not others. For example, that it is acceptable to return a ‘defective’ body to a normal body. This is an established view in the medical profession as protruding ears and cleft palates are routinely ‘fixed’ and breast reconstructions following breast implants are routine ‘best practice’.[ii] Alternatively, some justify cosmetic surgery on psychological grounds, such as that it alleviates distress and anxiety and builds esteem and confidence.[iii]
This discussion would focus on the ethics of practices, seeking criteria to determine which surgeries could be morally justified, for example, those that return someone’s appearance to normality, and carry an acceptable level of risk. Some cosmetic surgeries are exceptionally high risk, for example, buttock implants (for a graphic description of the risks check out pages 102-103 of Perfect Me), but other procedures are relatively low risk, with breast implants regarded as routine surgery. But drawing lines between routine and extreme practices is complex. Many non-surgical and routine practices are much riskier than cosmetic procedures, including the very common practices of tanning and skin-lightening.[iv] On investigation the line between what is routine and what is exceptional is blurred to the point of invisibility. Elsewhere I have explored five possible criteria which might distinguish between routine and extreme beauty practices (including cosmetic surgery): first, necessary to meet minimum presentation standards; second, frequency; third, third-party assistance; fourth, time; and fifth, risk. Some routine practices, such as hair-cutting, require third-party intervention and time out and some frequent, even daily, practices carry significant risk and all practices (or none) can be regarded as necessary to meet minimal standards. Routine does not mean, as it often implies, daily and relatively undemanding grooming practices. The only definition of routine which holds throughout is “necessary to meet minimal standards”. However, while in every situation “necessary to meet minimal standards” applies, what those minimal standards are changes from group to group and sometimes from individual to individual, rendering the definition meaningless.
To argue about the rights and wrongs of engaging in cosmetic surgery is the wrong discussion to have.
If ‘routine’ is a movable feast then it is not a useful tool for defining permissible and impermissible practices. So where does that leave a discussion of cosmetic surgery? If we cannot draw lines between different practices how do we determine which surgeries are permissible? My answer is that we don’t, and we should not try. Not because it is hard to do, but because it is morally problematic. Approaching the discussion like this is wrongheaded, unhelpful and leads to the wrong conclusions. To argue about the rights and wrongs of engaging in cosmetic surgery is the wrong discussion to have. It leads to condemning people for having surgery or not having surgery. It is to take an unjustified moral high ground, effectively telling people they should not have cosmetic surgery, or not certain types, of surgery. It increases a focus on bodies, as we look for tell-tale signs of surgery, or criticise the flaws which lead people to have surgery. Such attitudes contribute to the climate of appearance policing and self-policing, in which individuals are blamed and shamed for what they do and don’t do to their bodies.
We blame individuals for acting to improve their appearance and we blame them when interventions go wrong. For instance, women were blamed in the PiP scandal and ‘botched’ surgery is treated as entertainment.[v] Shame and blame are evident across appearance discourses and that these emotions attach to appearance is regarded as normal and even inevitable. In childhood we learn to routinely shame bodies to the extent that “physical appearance is the number one reason why people bully”.[vi] From as young as three we attach negative qualities, such as laziness, to fat people.[vii] The answer is not to tell young people that ‘it’s what’s on the inside that counts’, and they should rise above appearance bullying and reject such trivial pursuits or vain indulgences. This is to misunderstand what is happening in our visual culture, where bodies have become selves, something which requires understanding and recognition, not dismissal. Appearance does matter – we might think it should matter less, and it doesn’t matter as much as popular culture would have us believe – but it does matter. Appearance bulling is the most prevalent form of bullying and pressures to live up to unrealistic appearance ideas profoundly shape the lives of girls and young women.[viii]
For those of us who don’t feel this pressure that is likely because of our demographic and group membership. Appearance norms are fundamentally communal – something which the individual framework makes invisible. The individual framing of the ethics of cosmetic surgery is premised on the view that going under the knife is a simple choice, open to everyone, everywhere, in a similar way. This wholly ignores the role of context, class and privilege, which are key drivers of engagement and non-engagement. Very few of us have absolutely no concern for being thin, firm, smooth and young. Those who don’t engage are generally members of protected communities, where non-engagement is common and even commended. It is much easier for Professors of Philosophy to reject make-up than it is for retail workers. Cosmetic surgery is increasingly normal, just another beauty practice. For example, in Brazil, there is talk of a ‘right to Beauty’ and cosmetic surgery is regarded as a form of ‘public health’ and it is generally agreed that the poor should be able to access such procedures.[ix] Cosmetic surgery is prevalent and normalised in South Korea and Lebanon, and increasingly non-surgical procedures are regarded as routine, for example, in the US.[x] The demands of body work are rising across demographics but they are not uniform. They fall more heavily on those who are not privileged in terms of class, education and race and fall less on those who are protected by privileged communities and who have alternative ways to access the goods of the good life.
If we want to live in a world where cosmetic surgery is less sought after and the highly modified body is less normalised (and very many of us believe this would be a better world), then the way forward is not to police or judge body modification or non-body modification.
Given the hierarchies of power, an “individual response”, judging individuals for whether or not they engage, expecting individuals to be resilient, and so on, is profoundly unethical. It is divisive and patronising, and fails to recognise privilege, as Virginia Blum states “we need to transcend feminist criticisms of body practices that can wind up being as shaming as the physical imperfections that drove us to beautify in the first place – as though some of us are superior to the cultural machinery while others desperately fling ourselves across the tracks of cultural desires”.[xi] We need to stop shaming and blaming individuals for appearance engagement or lack of engagement. The ethics of cosmetic surgery should not be about whether cosmetic surgery is permissible, but a social and cultural ethics which seeks to make a more just world in which individuals can flourish and in which pressures to be perfect are reduced.
If we want to live in a world where cosmetic surgery is less sought after and the highly modified body is less normalised (and very many of us believe this would be a better world), then the way forward is not to police or judge body modification or non-body modification. Rather, the way forward is to work together to make a kinder and more inclusive, less body-shaming and more body-celebrating culture.
When we shame bodies, whether for having surgery or for not having surgery, we shame people. One way to change the culture is to end body-shaming, and to name negative comments about other people’s bodies unacceptable discrimination or lookism, just as we once named unacceptable comments about women sexism. Not that long ago we didn’t have words for sexism. It was considered ok – even complementary – for bums to be pinched in the office and to be cat-called in the street. Attitudes to lookism could change just as dramatically as attitudes to sexism – and the virtual world makes this change more attainable. Simply because lookism is ‘normal’, that does not mean it’s acceptable, any more than sexism or racism is acceptable simply because it was once normal. Body-shaming – whether fat shaming, or a nasty comment about hair colour or a body part – can stay with you and make you insecure. It is not uncommon that cosmetic surgery recipients trace their unhappiness to a nasty comment at school, or from a mother or a lover. The ethics of cosmetic surgery must reject as unethical an ethics of individual engagement and embrace an ethics of public health and social justice.
[i] For example, Shelia Jeffreys argues that “western beauty practices from makeup to labiaplasty” (Jeffreys, 2005, 3) fit the UN definition of harmful cultural practices and should be prohibited (Jeffreys Beauty and Misogyny, Routledge, 2005).
[ii] In her book Intact Clare Chambers recounts the story of Hannah, whose doctor refused to perform a mastectomy without reconstructive surgery, despite Hannah’s strong preference for a flat chest post-surgery (Chambers, Intact, 2022). [iii] The extent to which cosmetic surgery does build confidence is an ongoing debate, as much of the data is problematic; self-reported testimonials by those who have had surgery and often funded by cosmetic surgery companies. Nonetheless, that it has this effect is often assumed to the extent that some public health funded systems, have funded cosmetic surgery in response to psychological distress. For example, the Netherlands in the early 1990s (Kathy Davis. Reshaping the Female Body, Routledge, 1995.)
[iv] The WHO has deemed the harms of skin lightening so severe it is regarded as a public health issue (WHO, http://www.who.int/ipcs/assessment/public_health/mercury_flyer.pdf) [v] For example, the TV series Botched stated aim is to “remedy extreme plastic surgeries gone wrong”. That it is successful entertainment is evidenced by the fact that it is now in its seventh series, and has had numerous specials and a spin off series Botched By Nature (https://en.wikipedia.org/wiki/Botched_(TV_series)).
[vi] Ditch the Label, 2019, The-Annual-Bullying-Survey-2019-1-2.pdf (ditchthelabel.org)
[vii] Jennifer Harriger “Age Differences in Body Size Steryotyping in a Sample of Preschool Girls.” Eating Disorders, 2015.
[viii] Repeated surveys report that appearance bullying the most prevalent form of bullying and yet it is the least acted upon, as appearance is not a protected characteristic. (Ditch the Label, 2019, The-Annual-Bullying-Survey-2019-1-2.pdf (ditchthelabel.org)). Repeatedly survey show that most girls feel they don’t measure up to the images of girls and women they see and over 70% would like to lose weight (Girl Guiding, 2018, https://www.girlguiding.org.uk/globalassets/docs-and-resources/research-and-campaigns/girls-attitudes-survey-2018.pdf.)
[ix] Alexander Edmonds. Pretty Modern: Beauty, Sex, and Plastic Surgery in Brazil. Durham and London: Duke University Press, 2010.
[x] Dana Berkowitz, Botox Nation New York University Press, 2017.
[xi] Virgina L. Blum. Flesh Wounds: The Culture of Cosmetic Surgery. Berkley, California and London: University of California Press, 2003.
Heather Widdows is the John Ferguson Professor of Global Ethics and Pro-Vice Chancellor (Research and Knowledge Exchange) at the University of Birmingham. Her most recent book is Perfect Me: Beauty as an Ethical Ideal (https://www.amazon.co.uk/Perfect-Me-Beauty-Ethical-Ideal/dp/0691160074/ref=sr_1_1keywords=perfect+me+widdows&qid=1574859206&sr=8-1). She is co-director of the Beauty Demands Network (http://beautydemands.blogspot.co.uk/) and leads the #everydaylookism campaign (everydaylookism.bham.ac.uk).
Disclaimer: Any views or opinions expressed on The Public Ethics Blog are solely those of the post author(s) and not The Stockholm Centre for the Ethics of War and Peace, Stockholm University, the Wallenberg Foundation, or the staff of those organisations.