Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert's commentary.
Last week, you voted on whether a hospital ethics committee should approve a horn implantation in a patient's skull.
Should the hospital ethics committee approve this novel procedure?
Yes: 16%
No: 84%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in.
Physicians have always had a complex relationship with body modification. As advocates for public health, doctors have championed restrictions on procedures considered dangerous. For example, the risk of hepatitis led medical groups to petition for bans on tattooing in the 1960s, such as those that were enacted in Massachusetts (1962-2000) and New York City (1961-1997).
However, as members of a guild concerned for their "turf," physicians have also lobbied heavily to keep all body modifications under the exclusive purview of the medical profession. In 1976, the Arkansas State Medical Board fought a legal battle with Edna Hicks, a cosmetologist who performed ear piercing in her shop. The medical board argued that the piercings were a form of surgery and constituted the practice of medicine, so they should only be available from a licensed physician -- but the courts disagreed.
Since that landmark case, a peculiar division appears to have arisen between so-called "cosmetic procedures," which are generally done by licensed medical professionals, and "body modification" services, which often occur in tattoo parlors. Yet the bounds between these two divergent worlds remain porous and subjective.
It is also worth noting that the line between a cosmetic procedure and a medically necessary one is highly problematic. For instance, should breast reconstruction after mastectomy be viewed as essential healthcare or an elective luxury? Congress waded into this debate in 1998, passing the Women's Health and Cancer Rights Act, which requires private insurers who cover mastectomies to also cover reconstructive breast surgery.
In the well-known case of teenager Kevin Sampson, whose mother was a practicing Jehovah's Witness, the courts confronted the question of whether to order surgery for a facial growth that doctors described as unsightly but not life-threatening. Kevin's mother, Mildred, objected to the blood transfusion necessary for the surgery and argued that the procedure was purely cosmetic.
For ethicists and policy makers, the regulation of body-modification practices becomes most challenging with regard to interventions that pose some danger, especially when done in a private setting, yet which licensed health professionals are generally not interested in performing.
One such phenomenon is tongue splitting or tongue forking. The procedure, which bifurcates the tongue through cutting or cauterization, sometimes allowing each fork to move separately, is desired by some for either aesthetic or sexual purposes, or both. It was popularized by a body-modification advocate nicknamed the Lizardman in the late 1990s. Although the Lizardman had his bifurcation performed by an oral surgeon, many others pursue the surgery at specialized parlors or perform it themselves, as did body-modification pioneer Dustin Allor in 1996, resulting in considerable publicity.
Yet the procedure carries considerable risks, ranging from reduction of sensation to significant blood loss; in theory, severing an artery could lead to death. As a result, a number of states, starting with Illinois in 2003, have restricted the practice of tongue splitting to oral surgeons and related professionals. However, oral surgeons are not racing to replace body-modification artists in this enterprise, leading to a decline in the availability of the procedure. In some places, the restrictions are, in practice, a de facto prohibition. Critics argue that the result has been an increase in risk to the community, as would-be tongue splitters are not deterred, but rather driven underground for surgery. "Corset piercing," along the spine, and eye tattooing raise similar issues.
One might take the absolutist position that hospitals should not permit any cosmetic procedures involving meaningful risk, including nose jobs, tummy tucks, and face-lifts, as well as breast reconstruction or enhancement. After all, doctors have a duty to do no harm. However, if one accepts the psychological benefits of cosmetic intervention as justifying these more common interventions, one is hard-pressed to argue against Dr. Daneeka's plans for Maddie. One woman's breast enhancement, after all, is another woman's giant fiberglass horn.
Denying Maddie the appearance of her choosing seems both arbitrary and based upon culturally embedded norms that could easily change. Who can say that, in a generation, such horns will not be as common as pierced earlobes? More importantly -- from the standpoint of health and safety -- individuals seeking unconventional cosmetic procedures should not be shut out by mainstream medicine, which could lead them to pursue high-risk surgeries conducted by amateurs in a black market.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
And check out some of our past Ethics Consult cases:
Is Doctor Liable for Withholding Patient's Diagnosis From Family?