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MARGARET OLIVIA LITTLE


Cosmetic Surgery, Suspect Norms, and the Ethics of Complicity






Cosmetic surgery is often cited as a paradigm of “medical enhancement.” 1 Most of the time, this classification is meant to signal the view that such surgery is not medically necessary – not needed, that is, for the maintenance or restoration of health. Under one publicly popular picture of what moves people to have cosmetic surgery (what we might call the “Beverly Hills" picture), such a conclusion follows from the view that the surgery isn't necessary in any sense: it is a luxury, motivated by pleasure - and pleasure born of vanity, to boot - rather than the need to avoid or end suffering. In reality, of course, the landscape is more mixed: while there are cultural enclaves in which the pursuit of "beauty by scalpel" is as excessive as any parody might imagine, requests for cosmetic surgery are often motivated by deep and genuine suffering, in which surgery is pursued, not from a desire for beauty, but from a desire to end a distressing sense of alienation from some body part or to escape incessant teasing. In these cases, classifying cosmetic surgery as beyond medical necessity is not meant to make light of the suffering, but to remind us that the suffering is not born of disease or physiological dysfunction: whatever necessity the surgeries might carry, it is not medical necessity. ­

Questions about cosmetic surgery's status as an enhancement in this sense of the term are clearly of importance when we are trying to decide whether its provision falls within the duties of medical prac­titioners and third-party payers. But there is another set of questions about cosmetic surgery's status as an enhancement that concerns a very different, and altogether more charged, issue-namely, whether it is appropriate for medicine to provide it. For enhancement is also sometimes used as a boundary concept, marking off the limits of what falls within medicine's purview; and questions recur about whether cosmetic surger­ies fall on the far side of that boundary. This set of questions concerns,




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not whether medicine must provide cosmetic surgery, but whether it ought to.

The question is most familiarly raised about cosmetic surgery tout court, expressing concern about the very idea of medicine using its interventions to alter appearances. Raised in this way, the qu estion is familiarly controversial. Those with a traditional conception or medi­cine's telos will be uneasy at the thought of using surgery to satisfy the dictates of fads and fashions, of incurring medical risk without providing medical benefit. Others will argue that the source of suffering is less important than the ability of medicine to alleviate it; indeed, some will extend the argument to ask why medicine shouldn't provide a little pleasure, and not just remove pain, as long as the risks aren't too high.

While this controversy is an interesting and important one, focusing our attention on the appropriateness of cosmetic surgery as such threat­ens to obscure a deeper and much graver issue about medicine's involve­ment with the cosmetic. Whatever we think about medicine being in the general business of altering appearances, I will argue that we should have special concerns about a specific class of cosmetic surgeries, ­namely, those whose moral status is complicated by their relationship to what I'll be calling "suspect norms of appearance." As I will explain, this moral issue is a nuanced one that won't be resolved simply by deciding how narrowly or broadly to draw medicine's telos or by weighing the risks and benefits of procedures to individual patients. In this essay, I want to isolate the nature of the concern I have in mind, to defend that it is important, and to suggest some of the implications it carries for the contours of medicine's moral responsibilities.


Surgery and Social Norms
Cosmetic surgery, as a class, is distinctive in that the suffering medicine is asked to alleviate is in some sense due to social attitudes and norms rather than some disease or biological dysfunction. What distinguishes the distress suffered over some aspect of one's appearance

from the pain, say, of a broken leg is that the former is parasitic on

some value or aesthetic norm that society happens to hold. Perhaps the patient has internalized the norm and wants very much to meet it; perhaps she herself does not accept it but suffers because those who do accept the norm treat her differently. Concerns with appearance, then, reflect the influences of social attitudes, values, and preferences. I want to urge, though, that not all norms and pressures about appearance


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are on the same moral plane. Let me give three sets of cases to illustrate what I have in mind.

For the first case, imagine a society in which double chins are regarded as enormously attractive. While deeply held, the preference for voluptuous chins is understood to be a matter of aesthetic taste: those who possess only one chin are not vilified; they simply aren't anyone's idea of the dream Saturday-night date. In this society, as in ours, people differ in how much importance they place on being attractive, and some will be blithely carefree about the whole issue; but we can well imagine a person who has come to suffer deeply because he has just

the one lonely chin. He has tried, we shall imagine, to shrug off this lack, to find compensating measures elsewhere in his life, even psychotherapy, all to no avail. He is self-conscious and miserable with his current chin, and requests a surgical implant.

The second case is all too real. Think of a young boy who has ears that stick straight out. Imagine further that he is one of the unfortunates who is teased mercilessly and constantly by his schoolmates and children of casual encounter. His parents have tried to comfort him and to offer him strategies for dealing with his tormentors, but to no avail. The taunting has begun to color his whole outlook on life: he becomes withdrawn, begins wetting the bed; his grades drop. His parents finally decide, with his enthusiastic support and relief, to request that a surgeon tuck his ears closer to his head.

The third case is also taken from our own society. Imagine a black person who, either because he has internalized certain messages or because he wishes to escape certain stigmas, requests procedures that will make him look more like a white European-narrowing the nose, thinning the lips, lightening the skin. Or again, imagine a woman who, increasingly distressed and dissatisfied with her size-eight body and the enormous gap she perceives between that body and the pictures of feminine physicality ubiquitous in popular culture, requests a series of surgeries that will bring her closer to the paradigm exemplified by super models--extensive liposuction, recontouring the cheekbones, perhaps a rib extraction or two, all finished off with breast augmentation.

Even if we stipulate that the levels of suffering are the same in these three cases, I want to urge that they are importantly different in terms of the moral considerations they raise. Start with the first case. Hopefully we can sympathize with the poor fellow who has but one chin: given his yearning to be attractive and the aesthetic tastes of his society, we can agree that he was dealt a bad hand in life's lottery. But in this sort of case, while the person suffers real pain that is indeed




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importantly parasitic on his society's attitudes and preferences, I don't think we would say that society is culpable for that pain. Society gets to have convergences of idiosyncratic preferences, tastes, fads, .and fashions. Such convergences will affect different people differently, but this difference alone does not mean that anything morally problematic is afoot. As the saying goes, not everything that is unfortunate is unfair. To give another example, in the United States more people are fanatical about basketball than about horse racing; very tall men therefore have a shot at becoming famous sports heroes in a way that very short men do not. A man whose sole desire in life is to reach mega-stardom in the sports world but who is only five feet tall has a dream that is very unlikely to come true. But again, while we may pity this person's distress and empathize with his misfortune, we should not regard it as pain that implicates society.

Turn now to the second case, to the boy whose ears stick out. Once again we find society expressing a certain preference, this time for a particular ear formation. In this case, though, something has gone wrong with society's reaction to those who deviate from the preferred appearance. Here the costs imposed for such deviation-the teasing, the ostracism-are grossly out of proportion to society's own reflective valuation of the norm. They are punitive, intolerant, in a word, cruel. In contrast to the first case, in which the society's aesthetic preference was strong but morally tolerant, in this case parts of society-children, say, and the parents, teachers, and other adults who are negligently permissive about the children's behavior-act immorally in the costs they mete out to those who fail to meet their preferences. We might call the attitude toward the boy a prejudice rather than a preference to mark the difference. Here society surely deserves blame for at least some of the boy's suffering-not because society has preferences or norms about appearance, but because it is immoral in its "enforcement" of those norms.

Now part of what is morally problematic about the third class of examples (illustrated by surgeries designed to make blacks look more white and women more like super models) is a similar inappropriateness in the enforcement of norms. Part of our unease about a black person being made to look more white results from the fact that the punishment inflicted on those with extremely black African features is often egre­gious, ranging from cruel teasing and ostracism to lessened opportunities in employment and housing. A similar story can be told for the norms of appearance that women face. While both men and women face pressures regarding their appearance, the pressures are neither

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symmetrical nor equal. Woman has tended historically to be defined by her appearance in a way man has not.2 The virtue of beauty has been more central to female virtues than it has to male virtues, and woman has been more tightly associated or identified with body than with mind (a point that reappears historically as a premise undergirding the conclusion that woman is less rational than man). 3 Norms of appearance turn out to be, then, not norms of a good-looking woman, but norms of a good woman, full stop. Deviations from these norms of appearance are thus more highly punished than those applying to men (the pressure to "make the most of oneself" is for women a pressure that bespeaks an obligation, not a desideratum). After all, a man who fails in this category has failed in something that is only incidental to his nature; a woman has sinned against one of her deepest charges.

Part of what is morally problematic about the third class of cases, then, is that the cost imposed by society for failing to live up to its norms of appearance is here excessive, punitive, unfair, or cruel. But this problem isn't, I think, the full story about the third class of cases. I want to argue that there is another, very important source of moral unease in this third category. What is also problematic about these surgeries, I want to urge, is that the very content of the norms of appearance they involve is morally suspect. We feel a heightened moral unease about these cases, I want to urge, because the norms of appearance at issue are grounded in or get life from a broader system of attitudes and actions that is in fact unjust.

Consider the norm of attractiveness at issue in surgeries designed to make blacks look more white. We are not dealing here with some whimsical aesthetic preference. It is no accident that the standard of beauty prevalent in the West favors white European features over black African ones. It reflects a long-standing tradition in which being black is devalued and being white is valorized. Indeed, it reflects the remnants of a time-honored view-supported through history by major social institutions, especially science and religion-that the races are hierarchi­cally arranged in nature, with the white race standing as the exemplar of humanity, while the black race, quite literally subhuman, stands closer to the apes.4 The racial and ethnic contours of our norms of attractiveness were shaped as part and parcel of this broader conception of humanity.

Our uneasiness at the example of the black trying to look more white, then, is not simply a result of the fact that it involves racial features. There is something more presumptively problematic about




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incentives and pressures for blacks to look white than there is about incentives and pressures for whites to play with the exoticism of looking black. The former takes place against a broad context of devaluing blackness and a pressure to assimilate to an unjust paradigm of hu­manness.

Once again the point continues with the norms of appearance that are applied to women. Throughout history, woman and the "feminine" has been cast in roles of contamination, infection, and danger. 5 The resulting alienation toward features regarded as distinctly or especially feminine gets reflected in the norms of appearance applying to the feminine: in some cultures, it appears as a hatred of female fat, in others, as a hatred of female body hair. In virtually all cultures, it shows up in the fact that women's norms of appearance tend to be farther from the natural, the average, or the usual than are men's (e.g. fewer decades of a woman's life than a man's count as candidates for beauty)­a point that helps explain why women's standards of appearance are usually much harder to meet than are men's. Further, as several historians have noted, the idea of beauty has been defined as the object of the male, not female, gaze.6 Given that the nature and worth of woman are seen as residing so largely in her appearance, subliminally we begin to believe that the nature and worth of woman reside largely, if not exhaustively, in her existence as an object of male gaze. Consequently, the content of women's norms of appearance have a much greater tendency to objectify women than do men's norms of appearance-a theoretical point that is borne out all too vividly when we look at images of women in "entertainment" and advertising.7 At heart, the norms of women's appearance reflect, not aesthetic whim, but distorted, unjust conceptions of woman herself.

In the third classification, then, the content of the standards is part and parcel of an unjust social ideology. The examples so far adduced have involved race and gender, but I don't mean to suggest that the problem is limited to these categories. Put generally, it seems to me that norms of appearance occupy a morally suspect status when their content reflects, flows from, and reinforces a system of beliefs, attitudes, and practices that together involve deep injustice. If anyone central theme is common to such oppressive systems, as we might call them, it is perhaps the view that some group occupies less than full human status; and certainly categories other than race and gender have been the target of such ideological exclusions. Take for instance the case of children with Down's syndrome. Such children have distinctive facial



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features that publicly "mark" them; as such they often encounter hurtful teasing and distorted expectations. At the very least such cases belong in our second category, as instances in which society is culpably cruel in the costs it imposes for failing to meet some norm. But such cases may also fit the third category, for the content of the norms invoked may well be morally suspect. That is, while it may be that we have a merely aesthetic dislike of the facial features typical of those with Down's syndrome, it may be that the reason we have such an aesthetic reaction is because of some historical association these features have with a certain conception of "idiocy," namely, one in which "idiots" were regarded as occupying something less than full human status. The extent to which such a conception continues subterraneously to inform those norms, and for the norms to reinforce a broader system of unfairly constraining practices, is the extent to which the content of the norms themselves inherit a status that is morally suspect.

The cases of cosmetic surgery that raise special moral concern, then, are cases in which the dissatisfaction or distress that people ask medicine to alleviate results, not from morally innocuous preferences, but from practices or ideologies that are morally troubling-for instance, suffering that stems from cruel teasing, or distress that arises from trying to meet the pressures of a norm whose content is steeped in injustice. The question now at issue is whether this concern is one that is relevant to the moral responsibilities of medicine. Does the fact that the demand for such surgeries arises in problematic contexts count as a morally salient consideration for medicine's practices; does it carry any ethical implications for medicine as an institution or for surgeons as individual professionals?

One mainstream view of medicine's responsibilities contends that it does not. According to this view, much as we may abhor the attitudes and pressures that lie behind such surgeries, it is not and cannot be within medicine's purview to pass judgment on them or to use them as factors in determining what surgeries should be performed. After all, it is urged, to perform a surgery is not to agree with the values underwriting the request-physicians often disagree with patients' val­ues or preferences, but respect for patient autonomy requires that they not automatically substitute their own values for the patient's. In short, while the moral unease we feel at surgeries designed to make blacks look more white or women look more like super models may point to an important agenda for general society, medicine's role-specific duty must be to bracket these concerns, to take the situation as it is



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found, and to focus on its primary charge: having compassion for patients' suffering and alleviating it where possible.

However appealing such a view is on first glance, it fails to do justice to the moral contours of the situation. Whatever we might decide about the all-things-considered moral permissibility of performing such surgeries, we must surely agree that they call for some sort of moral hesitancy. That is, a surgeon who finds herself in a community of Stepford women trying to look pneumatic, or in a racist state whose government pays for blacks to look more white, must surely feel some moral unease at using her role to such purposes. To put it somewhat differently, even if the surgeon decides to go ahead with the surgeries­ alleviate, say, the extreme censure the patients would otherwise face-there will be a moral residue to doing so. But the model of medical responsibility that underwrites this response provides no means for explaining or grounding this modest, and thoroughly intuitive, notion. Even if the suspect nature of the norms leaves the surgeries permissible, it is far too strong to say that it is of no moral salience to the surgeon at all.

I think that the mainstream model gets the wrong answer because it's looking in the wrong place. It assumes that the moral covenant at issue in these worrisome surgeries is the surgeon's covenant to the individual patients who stand before her. It casts the moral question, that is, in terms of the physician-patient relationship, an approach which, not surprisingly, delivers the familiar advice to alleviate the patient's suffering and respect his autonomy wherever possible. But the moral complication such surgeries present to medicine concerns another rela­tionship altogether-the relation between the surgeon, or indeed medi­cine as an institution, and the suspect norms and practices themselves. We focus the moral issue too tightly if we focus only on the duty to relieve suffering, for as real as this duty is, there is a further issue about the physician's relationship to the system that causes that suffering. The deeper moral issue these cosmetic surgeries raise is, in short, the issue of complicity.



Acting with Integrity


What is it permissible to do in the face of cruel bullying or of pressures backed by suspect norms? When is it acceptable to accommo­date these pressures, and when does doing so count as "selling out" or "giving in"? What paths from suffering can one take without a loss of





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integrity? When is one to be cheered for taking measures to escape the unfairly punitive system, and when is one to be judged an "Uncle Tom" or a "recruit of the patriarchy"? These questions hopefully give some indication of the complexity of the moral terrain here. Concerns about complicity are nuanced concerns. They are not reducible to moral con­cerns about the aggregate net utility of one's actions, or to concerns about the wrongs one might do to some specified individuals. To be complicitous is to bear some improper relation to the evil of some practice or set of attitudes. Just what relation is it?

Put in broadest brushstrokes, let me suggest that one is complicitous when one endorses, promotes, or unduly benefits from norms and practices that are morally suspect. How we unpack this schematic answer depends on the context, of course. Certainly, the worst cases are those that involve explicit (if sometimes subtle) endorsement and exploitation of the norms and practices themselves. In the practice of cosmetic surgery, we find this sort of crass complicity represented all too well. The widespread practices of advertising to create demand, of underem­phasizing risks and overclaiming results, of suggesting procedures over and above the ones initially requested by the patient, are bad enough; the point here is that the promotions often exploit the suspect norms themselves. When the surgeries suggested to blacks are predictably for narrower noses rather than broader ones, when advertisement rhetoric plays to women's anxieties that anything over size four is fat, when patients report that surgeons suggest breast augmentations more often than they suggest breast reduction, we have patterns that reflect and endorse the content of the suspect norms. Matters are worse when such exploitation is done for the purpose of personal gain. Whether or not medicine in general should be pursued simply to make money (an issue I'm bracketing here), performing surgeries involving suspect norms solely for personal gain deserves heightened scrutiny-think of acting the Uncle Tom to make one's second million. Indeed, whatever the motive, there is something presumptively troubling about a practice that reaps profit from making society more white and women more like Barbie Dolls, if only because those who profit from the system run a tremendous danger of becoming invested in seeing it continue.

There are, then, cases in which practitioners of medicine have, in essence, "sided" with the suspect norms of appearance, exploiting their content and counterfactually sustaining their force. These cases deserve our ethical scrutiny and our ethical censure. But the theoretically more



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challenging, because more subtle, aspect of complicity remains yet to be addressed. Obviously, the picture presented here, while depressingly common, does not describe all cosmetic surgeons. Just as patients have a variety of motives for requesting cosmetic surgery, not all of which fit stereotypes of shallow vanity, surgeons have a variety of motives for performing such surgeries, not all of which fit stereotypes of cynical exploitation. Many surgeons are morally decent folk-a few even mor­ally heroic-whose intentions betray no endorsement of the norms that underwrite many patients' requests. They decry the pressures that lead to patients' suffering, much as they would decry the prevalence of a virus, and would change that aspect of society if they could; in the meantime, though, they are motivated by the genuinely noble goal of relieving the distress they find. (Indeed, the now-classic moral defense for performing frivolous or worrisome cosmetic surgeries is that it funds pro bono work doing reconstructive surgery on those with severe disfigurements).

Certainly, we want to mark off these activities as different from the crass ones. But the deeper question is whether the difference is sufficient to free them from all dangers of complicity. The question is whether purity of motive suffices to insulate actions. Take, for instance, first-person worries about one's own possible complicity. Such questions only arise when one abhors a system-one wouldn't worry about partici­pating in an activity one endorsed. The surgeon who is asked to make blacks look more like whites under a system of apartheid feels tension at the prospect of performing such surgeries precisely because she regards apartheid as evil. Questions about complicity often start, not end, with the judgment that one disapproves of a system or practice. Reflecting on these points presses us to question whether an approach that grants us absolution from complicity as long as we don't want to support a suspect system might be drawing the moral lines too cleanly.

The residual concern is that complicity might arise, not just when one subjectively endorses the suspect system, but when one's actions in fact end up reinforcing it. Clearly, one's actions can de facto serve to promote a system one does not intentionally set out to bolster, and the danger is particularly deep for the actions of medicine. For one thing, medicine enjoys an extraordinarily high institutional status in society; its participation in such surgeries can easily be regarded as sanctioning the importance and appropriateness of those norms. When the institution of medicine helps turn society white or women into

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Barbie Dolls, those maneuvers can seem to be backed by one of the central institutional authorities of our society. Further danger arises from the fact that the institution of medicine, in addition to occupy­ing high status, is primarily concerned with health and healing. Its participation can unwittingly bring suspect surgeries under that um­

brella, so that the norms of appearance get blurred with norms of "health" and "normalcy," reinforcing sexist and racist conceptions of what the paradigm human is like. And the mere fact that medical

interventions, which in general are associated with risk and invasiveness, are used to achieve some end tends to elevate the importance of that end: the tacit inference is that it must be worth doing, and not simply idiosyncratically desired, if it justifies taking such risks. (This outcome is especially true when surgeries are designed merely to gratify a patient's desire to meet the norm. When the deployment of medicine's social role is not the alleviation of suffering, but the satisfaction of the desire to meet a norm of appearance, the norm itself becomes elevated in stature-the opposite of what we want to see happen when the norms are suspect.)

But what are the contours of moral responsibility here? Are we now to conclude that duty demands us to avoid anything that will causally reinforce a suspect system? Do our own conceptions of our actions count for nothing? If we are tempted by the view that intention is the sole arbiter of complicity, it is surely in part because we recoil at the thought that the morality of our actions should be held hostage in this way to the existence of the suspect system, which would end up not only causing harm but grounding a startling extensive prohibition against measures that might help alleviate that harm.

The question here is what counts as "participating in" a suspect system one does not endorse; and it misses the nuance of complicity simply to equate that notion with causal reinforcement of a system.

For the nuance of complicity (and the reason I think it is such a useful concept) is located precisely in the fact that responsibility for such causal effect should sometimes be laid at our doorstep and sometimes at the doorstep of the suspect system.

Let me suggest a different approach to the issue. When even well­ intentioned actions unwittingly playa large role in legitimizing and reinforcing the suspect norms under discussion, they do so because of the meaning that those surgeries carry for others-they do so because others see in them a legitimization of or pressure to meet norms. This


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approach gives us better direction for understanding the terrain of

responsibilities here. Clearly, one should not be held hostage to all possible interpretations of our actions, to all the meanings others might attach to our behavior. But it is negligence to ignore the interpretations that others may naturally be expected to place on our actions given the broad context in which they take place. That is, while one is not responsible, for instance, when others willfully or negligently misinter­pret one's actions, one cannot simply turn a blind eye to all but the meanings one wishes others would see in our actions: we have a duty to forestall those interpretations that, while unintended, would be completely natural given the larger background context in which the action takes place.

If something like this notion is right, then the key to analyzing complicity is found when we remember that the meaning carried by actions, just as the meaning carried by words, is determined holistically. It is not found in individual features of an action-it is not equivalent to its effects, and it is certainly not solipsistically determined by our intention. Meaning emerges, rather, as a function of a broad context, including, significantly, the backdrop of other actions one performs. This idea suggests that we refocus our moral attention. Instead of examining the morality of an individual piece of surgery, we must examine the context in which that individual act of surgery takes place. The broad implication is, in essence, a conditional form of the motto, "If you're not part of the solution, you're part of the problem." If one must perform surgeries to help people meet suspect norms of appearance (out of concern for their suffering, say), then one must maintain an overall stance of fighting the norms. The only way to participate in the surgeries without de facto promoting the evil whose effects one decries is to locate the surgery in a broader context of naming and rejecting the evil norms. One's purpose and meaning-that of alleviating the extreme burdens the system places on some-can be expressed only if one's broader actions stand squarely against the norms.

Even in pursuing surgery from motives that are distant from the suspect norms, then, one must be cognizant of, and take into account, the possible side effects of one's actions. One has a responsibility to maintain and make clear the meaning of the action, and to factor in the increased pressure others may in fact feel as a result of having surgically "improved" appearance. At the very least, this responsibility would require those who perform the surgeries to speak out publicly





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against the suspect content of the norms-to be a general voice against, rather than promoter of, the norms and practices in question. But it will also issue in more specific recommendations driven by the specific contours of the suspect system's content. Let me give an example drawing from the case of women's appearance.

A true appreciation of the special injustices underlying norms of women's appearance would influence and enrichen our idea of what constitutes proper informed consent for such surgeries. Take for instance the matter of informing patients of the options they face. It may seem needless to recount the option of not pursuing surgery, but in fact doing so is not at all unimportant. One of the insidious ways sexism works is by gradually constricting the options that women imaginatively conceive for themselves. Such constriction happens, of course, with women's norms of appearance: the presumption for certain appearances is so heavy that our models of acceptable appearance occupy a narrow range. Medicine can take proactive steps to counteract this constriction by responsibly underscoring the option not to pursue surgery.

I don't mean that medicine should issue some vague admonition for women to rest content with their current appearance: to do so would be naive if not condescending. But far more use could be made of women's own differing experiences with cosmetic surgery and appear­ance. Some prospective patients arrive at medicine's doorstep less decided on the procedures than others. It would help stretch their imaginative options if one gave these women access (through videos, conversations, or written narratives) to a wide variety of women's experience: experiences from women who decided to go through with the surgery and are happy, from those who did so and have regrets, and from women who decided in the end not to have the surgery at all. And, again, it is important for women to have access to studies and narratives that bring to life the various real-life experiences women have of their bodies and society's reaction to them, not only that benefits are portrayed more realistically, but that the dangers and risks-social as well as medical - are understood. To give just one example, some defend breast augmentation as empowering, for large breasts enable one to "rivet men's gaze."8 But it is not the power to rivet men's gaze when and only when one desires that gaze, and there are many circumstances in which having a man's gaze riveted at one's breasts is anything but what one desires, as when one is trying to be taken seriously as a job candidate.


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Conclusion


Whatever we think of the general idea of medicine altering appear­ance, we should have special, and deep, concerns about medicine partici­pating in practices that reflect and reinforce certain suspect norms of appearance. Medicine and surgeons must beware the extent to which their participation in cosmetic surgeries involving such norms ends up contributing to a broad and unjust system of constraining pressures and forces. For while we want to alleviate what can be very real pain, the danger arises that, in doing so, we will be acting in a way that is complicitous with the very evils that give rise to it.

Yet there is surely some role for medicine to perform surgeries even in cases involving suspect norms. There is a limit to the suffering we require victims of the norm to bear before taking measures to escape that suffering, and health care professionals are sometimes the only ones who can alleviate that distress. Determining medicine's proper role in helping people meet suspect norms of appearance, then, is a complicated task, for there are two relations a physician must properly juggle-her relation to the individual patient, and her relation to the system of norms.

The tension between the duties grounded in these respective rela­tions, I have argued, can be somewhat lessened when we remember that the relation one must maintain to the norms is holistically defined: one must, if one participates in such surgeries at all, maintain an overall stance of fighting against the system. Such a general stance can leave room for occasions of helping a distressed patient by performing surgery that admittedly involves the suspect norms. There is all the difference in the world, that is, between, on the one hand, a surgeon who promotes, suggests, and aggressively advertises these surgeries, who performs them whether the patient requests it out of self-abnegation, desire for power, or anguish, who is glad when, for instance, trends in women's figures and faces change because shifting fads mean repeat business, and who is vaguely pleased that there is so much pressure on women to meet the norms because it means increased profits, and, on the other hand, a surgeon who does not suggest or promote the suspect surgeries, who helps her patients explore other options, who speaks out against the pressures women face, but who occasionally uses her surgical skills in cases where there seems no other path out of true suffering. Medicine does indeed have two duties to attend to when


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thinking about whether to perform the troubling surgeries, but I think they can be somewhat reconciled: sometimes perform the surgery, and always fight the system.


NOTES


1. This article is a companion piece to my article, "Suspect Norms of Appearance and the Ethics of Complicity," in In the Eye if the Beholder: Ethics and Medical Change if Appearance, ed. Inez de Beaufort, Medard Hilhorst, and Soren Holm (Scandinavian University Press, 1997), pp. 151-67; some paragraphs in this essay are taken from that article.

2. See Sandra Lee Bartky, Femininity and Domination: Studies in the Phenome­noloBY if Oppression (New York and London: Routledge, 1990), especially chapters 3 and 5; Susan Bordo, Unbearable Weight: Feminism, Western Culture, and the Body (Berkeley: University of California Press, 1993).

3. Sherry Ortner, "Is Female to Nature as Male Is to Culture?" in Women, Culture and Society, ed. Michelle Zimbalist and Louise Lamphere (Stanford: Stanford University Press, 1974-); Carolyn Merchant, The Death if Nature (San Francisco: Harper and Row, 1980); Genevieve Lloyd, "Reason, Gender, and Morality in the History of Philosophy," Social Research 50, no. 3 (Autumn 1983): 4-90-513.

4. For examples and discussion, see Stephen Jay Gould, The Mismeasure



if Man (New York and London: W.W. Norton & Co., 1981).

5. See Merchant, The Death if Nature, and Lloyd, "Reason, Gender,

and Morality."

6. Arthur Marwick, Beauty in History (London: Thames and Hudson,

1988); Reena N. Glazer, "Women's Body Image and the Law," Duke Law

Journal 4-3 (1993): 113-4-7.

7. See Susan Bordo, Unbearable Weight.

8. I am indebted to my colleague Alisa Carse for the example and

skeptical analysis.





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