AMA Journal of Ethics^®

Case

Ms. Wagner has been a patient of Dr. Holmes, a general practitioner, for over 15 years. Ms. Wagner is 51 years old and recently became a partner at a prominent law firm. She is in generally good health but takes prescription medication for mild hypertension and seasonal allergies, so she comes in every few months. Approximately five years ago, after the death of Ms. Wagner's mother, Dr. Holmes prescribed antidepressants and recommended counseling because she was having some difficulties at work.

During a recent visit to renew a prescription for her blood pressure medication and request a prescription for a sleeping aid, Ms. Wagner told Dr. Holmes that she had been considering cosmetic surgery. She wanted to "make some improvements" on her eyes, chin and forehead—hoping to appear younger. Due to her recent promotion, Ms. Wagner had more face-to-face contact with clients. She seemed very happy about this promotion and talked about how much she loved her job. She admitted that her new responsibilities had increased the pressure she felt to look good at work. She mentioned that her appearance was discussed during her promotion review but did not elaborate. Ms. Wagner also mentioned that she was becoming increasingly self-conscious about her age. She had taught high school for 15 years and had not entered law school until she was in her late 30s. Due to this somewhat late start on her legal career, she was a bit older than the other lawyers who had recently made partner at her firm. Ms. Wagner, who had always maintained a stable, normal healthy weight, had lost almost 15 pounds since her last visit six months before. When Dr. Holmes asked about dieting methods, Ms. Wagner laughed and said, "I guess I've been so swamped at work, I've been forgetting to eat."

Dr. Holmes asked Ms. Wagner how much research she had done on cosmetic surgery. Ms. Wagner said she had not done any research but had made up her mind about undergoing the procedures. She asked Dr. Holmes to recommend a reputable local cosmetic surgeon. Money was not a problem for her, and she said, "The potential impact a new face will have on my career is worth some temporary pain and swelling." Dr. Holmes personally believed that unnecessary surgery for aesthetic reasons was not worth the medical risks but wanted to give appropriate medical advice.

Commentary

Headlines about beauty are as ubiquitous as reports on the weather. They're everywhere, screaming at us to be thinner, prettier, younger. And nowadays, plastic surgeons with well-honed skills and fancy academic appointments have merged medicine with marketing and taken their show to suburban malls, opening Botox boutiques where nurse practitioners play doctor with people's faces [1]. Everyone wants a piece of the cosmedicine world, a "happy" place where a full-time anesthesiologist can become a part-time aesthetician and "make a few bucks" by wielding a laser at a beauty salon [2]. No wonder Nora Ephron feels bad about her neck [3].

Meanwhile, the American workforce doesn't exactly welcome age. Regardless of their experience or skill, commercial airline pilots must retire at 60. A group of television writers over the age of 40 has brought a class action suit alleging age discrimination against certain Hollywood studios, broadcast networks and talent agencies. Greeting cards joke about aging, but, for many people, there is nothing funny about it. It has become, fairly or not, synonymous with uselessness, ugliness, and, from an employment perspective, a rather short goodbye.

In the case presented here, Ms. Wagner's concerns are understandable. Couple the social pressures about beauty and aging with the recent changes in her own life—a promotion, pressure at work to look good, increasing concerns about competing with younger colleagues—and it is easy to see why she wants to "make some improvements" through cosmetic surgery.

Yet Ms. Wagner's case raises red flags that should give Dr. Holmes pause and guide his actions. For one, he should screen this patient for depression. Ms. Wagner may have a history of depression, given her course of antidepressants and counseling five years ago, and her recent promotion is a stressful, albeit positive, event. She has also lost 15 pounds, experienced a drop in self-esteem, and complained of difficulty sleeping—all possibly associated with depression. Although cosmetic surgery may have psychological benefits, it may not be a panacea for patients who need psychiatric care. In fact, studies suggest that such patients may be unhappy with their surgical result and face "postoperative psychological complications" [4,5]. Even if Dr. Holmes offers recommendations about cosmetic surgeons, he should also suggest that Ms. Wagner meet with a mental health professional and explain why he thinks such a consultation is in order.

Dr. Holmes should also discuss the perils that are apparently inherent in partnership at Ms. Wagner's current law firm or recommend someone who can. That Ms. Wagner's appearance came up in a promotion review is troubling, if not potentially illegal, and stressful. To be sure, appearance is important in the workplace. But it is one thing to present a neat and professional look; it is quite another to work in a law-firm-cum-beauty-pageant, where looks are part of the calculus for success. Although she says that she loves her job, both her psyche and her career may benefit from moving to a firm that is more interested in cultivating good lawyers than it is in rewarding good-looking ones. Because she is now a partner, Ms. Wagner may have gained the requisite clout she will need to make such a move.

While Dr. Holmes may not agree with cosmetic surgery, his personal beliefs should not dictate the advice he offers to patients. In recent years, a sort of "practice what I preach" medicine has emerged. Physicians and other health care professionals have refused to offer information about some procedures or fill prescriptions for certain medications which ostensibly violate their personal beliefs. Arguably, that behavior chips away at what it means to be a professional—to put patients' needs ahead of one's own, to offer a panoply of options as part of an informed consent process, to fulfill the basic requirements of the job. In a case where a police officer was fired after he refused to patrol a casino (gambling violated his religious beliefs), the 7th Circuit Court of Appeals held that civil servants may not pick and choose their job assignments [6]. Writing for the court, Judge Easterbrook noted, "Firefighters must extinguish all fires, even those in places of worship that the firefighter regards as heretical. Just so with police" [7].

Perhaps a variant of that principle—that those who serve the public must put the public first—should apply to doctors. With their specialized knowledge and extensive training, (much of it on the public dollar), they should have a duty of candor to patients—to present all options, even those they might not choose for themselves. Informed consent demands nothing less. Thus, Dr. Holmes should discuss the risks and benefits of cosmetic surgery, and he may even offer his opinion, but he should provide the names of reputable and board-certified plastic surgeons. After all, just about anyone with an MD can call himself or herself a "cosmetic" surgeon, and most members of the general public have no idea that there is a vast difference between a board-certified plastic surgeon and a cosmetic surgeon. Without professional advice, Ms. Wagner may be left to find a surgeon on her own. As great as Internet search engines are, they are no substitute for a professional recommendation about a physician.

If Ms. Wagner wants cosmetic surgery and has realistic expectations about such surgery—it may not be a perfect salve for insecurity and it cannot excise time—then she should certainly continue to research her options. Her body is her own, and, subject to the above caveats, if she wants to change it, she should be offered the information she needs to do so. But she may not need a new face. She may need a new law firm. And she may need to come to terms with a difficult reality: that time moves in one direction, and for many people, 50 isn't fabulous. It's downright depressing. Cosmetic surgery may be a coping mechanism, but it is only one strategy among many.