About ten years ago I was at a meeting and we were discussing what the policy on female genital cutting (FGC, female genital mutilation (FGM), or female circumcision) should be in the hospitals of the Canadian city where I was living at the time. The woman who was giving the presentation about the facts of FGC said at one point in the presentation that there was “no benefit” to FGC that could be weighted against its harms. Now, I do not support FGC in any way, but I was also quite bothered by this statement because it is one that renders the women who engage in FGC unintelligible and irrational, which makes discussing FGC with women impossible. I have been thinking about this issue again because I recently saw this video about the increasing requests for labiaplasty in Australia (The video is NSFW):
ETA: The video “Labiaplasty” by The Hungry Beast is available on Vimo for viewers outside of Australia, or on ABC Australia for those within Australia (they also did a follow-up story called “Digital Labiaplasty“).
Although the commentators in the video are very critical of labiaplasty and the social context that gives rise to requests for labiaplasty, the procedure and the women who request the procedure are discussed in ways that make the decision intelligible. Although the reporter clearly thinks the requests are ill-advised, they are not made to seem irrational given the social context. This is quite different when contrasted with the discussion of FGC that I mentioned above. I want to look at some of the reasons for these differences.
1. Background of Standard Bioethics Theory
There are a number of approaches to bioethics, but one popular approach is the “principlist” approach with Tom Beauchamp and James Childress’s book Principles of Biomedical Ethics (now in the 6th Edition published 2009) as one of the most well-recognized articulations of the view. I will explain each of the four principles, but I am particularly concerned in this post with the idea of “beneficence” and how ideas about what counts as a benefit can affect whom we consider to be autonomous. Because of group-based differences, the principles of “beneficence” and “autonomy” can interact in ways that are racist, sexist, classist (and so on).
The principlist approach outlines four principles that should be considered when evaluating the moral permissibility of particular medical treatments. These principles are:
- Respect for Autonomy: The principle of respect for autonomy captures the idea that people have a right to make their own self-regarding decisions. They have a right to determine the course of their own lives and doctors should not coerce patients or force patients to accept medical treatments if the patient does not want the treatment. This is usually put into practice through informed consent where it is the obligation of the doctor to inform the patient about the medical risks and benefits of a particular procedure and then should allow the patient to make their own decisions about whether they would like to accept or refuse the procedure.
- Non-Maleficence: The principle of Non-maleficence indicates a commitment to not inflict harm on patients. It is an ancient principle found in the Hippocratic Oath as Primum non nocere or “First (or ‘above all’) do no harm.” Principlists recognize that there are many kinds of harm (for example, harms to reputation, privacy, psychological harms and physical harms). In the context of bioethics, theorists tend to focus on physical harms, like pain, suffering and death. They will also allow the importance of psychological or mental harms and harms to one’s interests, but the emphasis is on physical harms, especially medical harms. This principle says that doctors should not harm patients, but there is some balancing allowed here. For example, surgery causes pain and suffering, but these harms are often outweighed by the benefits of surgery. If one has appendicitis, then the surgery to remove the appendix might be painful, but the surgery can also be life-saving so the pain is justified by the way that it prevents death.
- Beneficence: This principle says that doctors should take positive steps to benefit patients. The principle of beneficence is closely linked to the principle of non-maleficence (do no harm), but it goes further than non-maleficence by saying not only should physicians avoid harming their patients, but they should also attempt to benefit their patients. As in the principle of non-maleficence, there are many types of benefits, but in the context of bioethics, the focus tends to be on physical benefits, such as alleviating pain and suffering and promoting good health.
- Justice: The principle of justice is quite complex because there are many different ways to understand what justice requires. In the context of bioethics, principlists understand justice to require fair distributions in access to health care. This principle also requires that the benefits and burdens of research should be fairly distributed. This is meant to protect populations that are vulnerable to exploitation. For example, the study population for any research trial should be the same population that will benefit from the procedure or medical treatment if it is found to be effective.
In what follows, I will concentrate on the first and third principles. I begin by discussing beneficence and what should count as a benefit and then I talk about how this can affect the principle of respect for autonomy.
2. What Counts as a “Benefit?”
The principle of Beneficence says that doctors should provide benefits to their patients. This principle is closely related to the principle of non-maleficence which instructs doctors not to harm their patients. In practice, the two principles are usually invoked together and the practical application of the principles requires weighting and evaluating the relative harms and benefits of a procedure. Sometimes this is discussed as finding the risk:benefit ratio. The weighting of the two principles recognizes that all medical procedures involve possible harms (or risks) and also possible benefits.
Decisions about medical procedures that use risk:benefit ratios occur at a number of different levels in medical contexts. For example, researchers will often use risk:benefit ratios to determine whether their new drug, procedure, or treatment is more effective than those that already exist. In these cases they will compare the risk:benefit profile of their new treatment to the risk:benefit ratio of existing treatments. Health Canada and the FDA (in the USA) also look at risk:benefit ratios when they are deciding whether to approve a new drug or medical procedure. If a procedure is too risky and does not have sufficient benefits to off-set the risks then it might not be approved for sale or use within a given country. Finally, after a drug or medical treatment is approved for use, risk:benefit ratios might be considered at the individual level when doctors and patients are deciding what course of treatment they will follow. The doctor might evaluate the patient’s individual risk profile, and decide which treatment(s) she or he would recommend to the patient. The doctor will then inform the patient of these risks and benefits of the various possible treatments and the patient has the right to evaluate the risks and benefits and then make decisions about their treatment based on the patient’s evaluations combined with the patients values (for example moral values, religious values, the particular fears they have, their preferences for different types of interventions, and so on).
Because risk:benefit ratios play a significant role in medical decision-making, it is worth thinking about what counts as a “benefit” in these decisions. As I said above, many health care ethicists say they give priority to medical and physical risks and benefits over other kinds of risks and benefits, such as social benefits, psychological benefits, material (wealth) benefits, and so on.
In some cases, however, we are quite willing to recognize non-physical benefits in discussions about certain kinds of medical procedures. In particular, when doctors have discussed plastic surgery non-physical benefits subtly influence the discussion more than they do in other contexts. In the context of plastic surgery, social and psychological benefits play an increased role in the evaluation.
Sometimes bioethicsts make a distinction between “reconstructive” plastic surgery and “cosmetic” plastic surgery. Reconstructive plastic surgery takes place to “correct ravages of disease and injuries as well as gross physical abnormalities,” according to Miller, Brody and Chung (2000). Reconstructive plastic surgery, they say, “constitutes a core medical practice.” In contrast, ‘purely’ cosmetic plastic surgery does not correct any medical problem, and is instead requested based on the “subjective” preferences of the patients.
Reconstructive plastic surgery takes place to “correct” things like cleft pallets, to reconstruct skin that was damaged by burning, to reconstruct breasts that were lost through mastectomy and so forth. In some cases physical functioning might be restored through these reconstructive surgeries (for example, when facial reconstructions help patients to eat again), but in many cases reconstructive surgeries are not done to restore functioning (for example, reconstruction after mastectomy restores the appearance of breasts but not their functioning). There are often a number of “cosmetic” elements in “reconstructive” surgeries, so that there is not really a sharp line between the two. Miller, Brody and Chung continue:
Reconstructive procedures, however, lie along a continuum, without any clear boundary between therapeutic reconstructive surgery for a diagnosable problem and purely cosmetic surgery. In addition, reconstructive surgery in response to deformity is guided by aesthetic considerations. Yet compare, for example, plastic surgery to remove a portwine stain causing severe facial disfigurement, but without any functional impairment, with liposuction to produce a trimmer appearance or a facelift to “rejuvenate” facial features. The former appearance problem qualifies as a malady that is objectively discernable by all observers, and it is reasonable to describe corrective surgery as medically indicated. In the latter cases the appearance problems giving rise to a request for cosmetic surgery are a matter entirely of subjective judgment. If surgery to remove a disfiguring port-wine stain is regarded as in part cosmetic, then at least some cosmetic procedures belong within the core of medical practice. This conclusion has no bearing, however, on the vast majority of purely cosmetic surgery procedures performed on normal bodies, which are not supported by the goals of medicine (Miller et al. 2000, 358).
Miller, Brody and Chung set before us the contention that there is a continuum between reconstructive surgeries and ‘purely’ cosmetic surgeries because even the former involve cosmetic considerations. Their arguments concerning the difference between practices at the two extremes are rather thin, however. They assert that a portwine stain is “objectively” discernable as a malady to any observer, whereas liposuction depends on “subjective” preferences. Here they offer no argument whatsoever and simply assume that their readers will come to the same judgment regarding the two cases. For this contention to make any sense, the reader must appeal to his or her own culturally informed intuitions about which aesthetic variations are “medically serious” or “objective” and which are “frivolous” or “subjective.” But these understandings actually require that the writers and the readers share a lot of cultural presumptions about what counts as a “medical benefit” and what counts as a subjective preference.
When the writers and readers share the same cultural presumptions there is a strong tendency for social benefits (such as fitting in, being accepted, seeming “normal,” not being ostracized, an so on) to creep into the evaluation. For example, I do not share their intuitions that “portwine” birthmarks are medical maladies. Often the major disadvantage of these marks are not functional, but instead involve the way that others in one’s culture will react if they see these marks.
There is a similar use of shared cultural understanding when discussing “purely” cosmetic procedures. For example, there are no medical benefits associated with breast augmentation surgery, liposuction, facelifts, labiaplasty and so forth. There are also considerable risks associated with these procedures (for example, see this Health Canada information page about breast implants). But because Western readers are familiar with these practices we can insert the cultural benefits, and even if we don’t think these procedures are appropriate, we can understand why someone might request the procedure.
When people who are a part of western cultures discuss cosmetic plastic surgery as it is practices in the west we are able to “fill in” the non-medical benefits. We understand that people who request facelifts are living in a culture that values youth and that appearing older has tangible negative effects on the lives of these patients (which is especially true for women). We know that attractive, thin women are more likely to have higher-paying jobs. So although there are no medical benefits to liposuction, we can easily “fill in” the economic benefits associated with this procedure. Even today, it remains the case that women’s social status is most strongly correlated with the social status of her partner (particularly her husband). In cases of divorce, women often find themselves in worse economic circumstances. So, in one sense a woman’s decision to get a breast augmentation can seem to provide a “benefit” if she correctly believes that it will improve her chances of attracting and retaining the interest of men
Although we might ask questions about whether these are actually legitimate benefits when all things are considered together, we would not be as likely to say that there are “no benefits” to cosmetic surgeries. Notice that this is the tone that is taken in the video I linked above. The reporter clearly does not support the practice of labiaplasty, but she does not conclude that there are “no benefits” or no reasons that women might request these surgeries. Instead, she reports how censorship around soft porn might give women false impressions about the appearance of “normal” female genitalia.
In contrast, when those requesting a procedure come from different social and cultural backgrounds, it is much more difficult to “fill in” these social benefits. We might conclude that there are “no benefits” in cases where we don’t understand the context. Although this might not seem like a problem, it has effects on whether decisions (and the people making these decisions) seem like autonomous agents.
3. Autonomy and Benefits: The Intelligibility and Rationality of Decisions
The principle of respect for autonomy captures the idea that mature persons should have the right to determine their own life. They should be able to make decisions about things that affect them and we should respect their right to make these decisions. Not all decisions are granted this respect, however. Usually patients must meet certain criteria before their decisions are considered autonomous. These criteria are:
- Competence and Reasonable Choice: Persons are competent to make decisions about their medical treatments if they have certain capacities regarding the particular decision. For example, they must be able to understand the information they are given about the medical procedure, and they must be able to make a decision based on this understanding and their own values. They should be able to understand their own situation and how the decisions they make relate to their situation. They should be able to understand the likely outcomes and consequences of the various possible decisions. They should also be able to articulate their reasons for choosing one course of action rather than another.
- Adequate Information and Understanding: The person should be given and should be able to understand the relevant information relating to the medical decision. It is the doctor or other health care provider who has the obligation to provide the information. The patient must be able to process, understand, and relate this information to his or her own situation and must be able to make decisions based on this information.
- Free from Explicit Coercion: There are a number of ways that a patient’s decision can be influenced, but the standard way to understand the criterion that the decision must be voluntary is to say that the decision should be free from explicit coercion or manipulation.
None of these criteria specifically address the issue of what counts as a benefit. Nevertheless, when we attempt to evaluate each of these criteria there is significant room for the interpretation to be affected by how we understand what counts as a benefit.
Benefits and Reasonable Choices: If there is truly “no benefit” to FGC, then the women who ask for FGC for themselves or on behalf of their daughters must have no reason to make the request. If we think there is no reason to make the request, then the decision will seem unreasonable and the competence of the mother might be called into question. If there are no shared cultural understandings, then the benefits of social inclusion disappear from the analysis and the request becomes unintelligible.
In contrast, when discussing labiaplasty, the benefits of social inclusion are more apparent to western doctors. They understand the concept that women might want to look like the pictures that they see in magazines and might be uncomfortable about their bodies if they do not look like these pictures.
Benefits and Adequate Understanding: If there is truly “no benefit” to FGC, and the physician simply informed women of the risks associated with FGC, then we would expect the women to decide against the procedure immediately. So by stating that there is “no benefit” to the procedure we also make any woman who does not immediately drop the request for FGC after learning of the risks into someone who is clearly irrational. If the doctor sees no benefit where the woman sees cultural benefits, then the doctor is more likely to decide that the woman does not demonstrate any understanding, cannot process the information, or cannot apply the information and the likely consequences of her request to her own situation.
In contrast, when western doctors consider requests for labiaplasty they will often “fill in” the cultural benefits of the surgery because they are familiar with the culture of the women making these requests. The doctor might disagree with the emphasis the woman is placing on these values, but because the principle of respect for autonomy requires that the decisions of competent, autonomous patients should be respected even when the doctor disagrees, the doctor should not attempt to impose his or her own values on the patient.
Benefits and Voluntariness: When we cannot understand the “benefits” of a particular procedure from the perspective of the person asking then we might conclude that the request is unintelligible or irrational. We become more likely to believe that the woman making a request for FGC must be a victim who is being controlled by someone else’s wishes. Since there is no benefit to her (as far as the doctor can tell) and there is considerable risk of harm, then it might seem likely that she is requesting this surgery for the sake of someone else. All of this makes it more likely that the State will take-over decision-making power from this woman.
In contrast, discussions about labiaplasty and other cosmetic surgeries are often discussed as the height of voluntary decision-making. These procedures can seem like the paradigm of “free choice” because there are no underlying health conditions that necessitate the procedures, and so the decision to undergo surgery is not influence by the sometimes painful effects of illnesses. Advertising for cosmetic procedures often emphasizes freedom, for example in this ad for Botox emphasizes freedom of expression and free choice:
These are serious issues because when a patient is deemed incompetent, they lose the right to make their own medical decisions. This limits the control that they have over their own lives. Furthermore, when someone’s decisions are considered unintelligible or irrational, then it no longer makes sense to reason with them or engage in discussion of the issue. An irrational person cannot be persuaded through reasoned argument. Unintelligible decisions cannot be understood through further discussion. State intervention or surrogate decision-makers seem like a better way to go.
I think the view that there is “no benefit” is racist because of the ways it fails to understand the perspectives of those who request the procedure while rendering the women who request the procedure simultaneously unintelligible (we cannot, and could not possibly hope to understand them) and irrational (we should not allow them to make their own decisions because they clearly do not understand what is in their interests).
Uncovering the way that shared (or differing) assumptions and values can affect what seems like a benefit is useful because it can also help to make the formerly unintelligible or irrational seem understandable. We cannot engage in dialogue, discussion, or criticism unless we can make these decisions understandable.
There are very legitimate reasons to criticize both FGC and labiaplasty. But the criticisms should take place in a way that respects the women who request these procedures rather than in a way that renders these women unintelligible or irrational.
Understanding how one’s perspective matters to these evaluations also makes it possible to criticize the practices of other cultures without demonizing those cultures. An awareness of the importance of perspective and cultural understanding does not plunge us into relativism in which no criticism can be made except from within the culture. But it does remind us that we need to be humble about our own understandings and presumptions.
Miller, Franklin; Brody, Howard and Chung, Kevin (2000). “Cosmetic Surgery and the Internal Morality of Medicine,” Cambridge Quarterly of Healthcare Ethics. 9:353-364.
 I do not support the interpretation offered by Miller et al. I think there are a number of problems with their analysis. I offer it here only because I think that it represents a very common or stanadard way that plastic surgery is discussed in bioethics literatures.