Division of Inappropriate Analogies: Surgery as Haircut
posted by Frank Pasquale
The NYT’s Natasha Singer reports that breast augmentation has become “the country’s most popular cosmetic operation.” Carol Ciancutti-Leyva (director of the documentary “Absolutely Safe”) warns women that they may be in for more than they bargained for:
Your implants may last less than 10 years or more than 10 years, but when you start having problems with them, your health insurance is unlikely to cover the M.R.I. tests or the reoperations. It can be a very expensive proposition, especially if you are young.
I wonder if company wellness programs will soon be asking women to reveal if they’ve had implants? But they shouldn’t worry about “maintenance” in general, says a past president of the American Society for Aesthetic Plastic Surgery, offering one of the more bizarre analogies I’ve seen:
Women are used to having their hair or nails done on a regular basis to maintain their appearance. Ultimately, breast implants may also be a matter of maintenance.
More on what this maintenance can entail after the break.
[A] rupture is only one of the local complications that may engender additional surgery. Like cocoons that grow around larvae, scar tissue can form around implants; and sometimes that scar capsule hardens and squeezes the implant, causing pain and deforming breasts. And saline implants can cause visible, tactile rippling beneath the skin.
[E]xplantation surgery, in which a surgeon removes implants for good along with scar tissue, can be more complicated, particularly for older silicone models. “If the envelope has broken down and the silicone has leaked out, you are trying to get out all of that goo,” said Dr. Susan E. Kolb, a plastic surgeon in Atlanta who performs three to five explantation surgeries a week. To remove scar tissue, which can adhere to muscles and to the fibrous tissue covering the ribs, some doctors mistakenly remove too much muscle or breast tissue, which can cause chest deformities, she said.
Despite all the risks, “[d]octors nationwide performed about 329,000 breast augmentations in 2006, up from about 291,000 in 2005, according to a survey of doctors from the American Society of Plastic Surgeons.”
I’ve proposed taxing cosmetic surgery before, and some cities (like Beverly Hills) are starting to target taxation in this way. Beverly Hills merely argues that “the centers become a drain on resources relative to the taxes they pay” (as Rhonda Rundle puts it in her article on the topic in the Wall St. J.). But if these interventions also “constitute the kind of annuity medicine that will entail regular surgical tuneups,” their externalities are larger than once thought. A 2007 article in the American Journal of Psychiatry on “Cosmetic Breast Augmentation and Suicide” suggests some even higher stakes:
Across six [epidemiological] studies, the suicide rate of women who received cosmetic breast implants is approximately twice the expected rate based on estimates of the general population. Although the first study of this issue suggested that the rate of suicide among women with breast implants was greater than that of women who underwent other forms of cosmetic surgery, the largest and most recent investigation in this area found no difference in the rate of suicide between these two groups of women. (Am J Psychiatry 2007; 164:1006-1013).
Given growing societal pressure to pursue such surgery, it might be easy to feel hopeless when “medical experts [have] said they could not determine exactly how long breast implants may last.”
One last note: a 1992 note by Emily C. Aschinger (entitled “The Selling of the Perfect Breast: Silicone, Surgeons, and Strict Liability,” 61 UMKC L. Rev. 399) anticipated the issue and proposed the following:
Plastic surgeons, through advertising, have created a demand for elective plasticsurgery. In the case of breast implants, the doctors who created the demand are now reluctant to deal with the problems these implants have caused. Many of these doctors refuse to remove implants from former patients who have experienced problems; however, these are patients upon whom they were all too willing to perform the initial unnecessary procedure.
Elective cosmetic surgery is less a medical practice that involves the health of the patient and more a marketed response to societal demands dictating that people must do anything it takes to live up to the ideal. [Old liability standards are] outdated[;] plastic surgeon should be held strictly liable from a products liability standpoint under [Restatement of Torts] section 402A for breast implants. . . . [I] explain how plastic surgeons have met the criteria for a seller of products and should be treated as such under section 402A.
As Ms. Aschlinger argued, “Someone must be held responsible for the many women who, as a result of defective breast implants, will be injured.” And also those who will find even “non-defective” implants the cause of health problems.
January 17, 2008 at 9:19 am
Posted in: Feminism and Gender, Health Law
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Responses (19)
Logical Extremes - January 17, 2008 at 10:26 am
Education is needed to counter omnipresent marketing influences. And certainly taxation, liability, and other forms externality mitigation are welcome. But I wonder if, taken too far, that course might just add to the allure by making the surgery even more of a positional good to distinguish ‘have’s from ‘have-nots’.
KipEsquire - January 17, 2008 at 11:18 am
Do you support taxing braces? Surely all that “unnecessary cosmetic dentistry” is imposing “externalities” upon “legitimate” dental practices.
Or how about infant male circumcision, which is also an unnecessary vanity procedure that “crowds out” other medical procedures?
More generally, do you ever have a basis for your policy proposals other than your own hubris?
Frank - January 17, 2008 at 12:30 pm
LE: great point on the paradoxes of intervention here. We do have to learn from the “anti-smoking” campaigns, which may have just added to its allure.
KipEsquire: I don’t think “braces are just like surgery” is much better than the haircut/manicure analogy. And I believe we have better evidence on the braces’ lasting effects than the implants.
Patrick S. O'Donnell - January 17, 2008 at 1:45 pm
Frank,
For the record, I’ve never imagined any of your policy preferences or proposals to be motivated by an alleged hubris. I’ve rather found them to reflect such virtues as empathy, compassion, intelligence if not wisdom, keen political judgment, and a legal scholar’s firm grasp of the breadth and depth of the relevant law. Moreover, they exemplify the energy and courage of one who holds steadfast to a belief in the egalitarian goal of universal human flourishing wherein everyone has not only their basic physiological, psychological, and perhaps even spiritual, needs met, but is able to progressively realize their capacities and potential over the course of a lifetime. I’m one reader who remains quite grateful for the consistently high quality of your posts.
Incidentally, only a cursory acquaintance with Judaism would disabuse one of the idea that infant male circumcision is not an “unnecessary vanity procedure” (it is a ’sign in the flesh,’ of the covenant made with Abraham). And some recent evidence suggest that it may even help in the fight against transmission of the AIDS virus.
Patrick S. O'Donnell - January 17, 2008 at 1:49 pm
Erratum: “*is* an unnecessary vanity procedure….
Daniel Goldberg - January 17, 2008 at 2:10 pm
I’m going to return the the tired old drum I beat on this issue in general: the lack of any neat distinction between therapy and enhancement, particularly once one understands the silliness of mind-body dualism.
That said, I certainly have no problem with trying to rank order procedures to try to capture some of the nuance and complexity of the issue, and even trying to better internalize the costs of procedures that seem to fall much closer to the “enhancement” domain. However, I do not agree with Aschinger’s notion that advertising created the demand.
Advertising may drive it and fuel it, but did not create it. The desire for breast implants is an intricate social phenomenon, caused by a number of different social, political, and economic factors, of which advertising is only one, and may even be more effect than cause.
Angela Segal - January 17, 2008 at 2:26 pm
Give me a break! Since when do other people decide what is necessary? If you have breast cancer and then surgery is it then ok to have implants? All this to do, in a country where we have decided that a man who can not acheive an erection has a diesease (ED)and therefore should have his medication covered by insurance! I advise my clients to go where the best options are. If that becomes a destination outside of the US because of increased uneccessary cost then so be it. http://www.AngelaSegal.COM
geoff - January 17, 2008 at 4:13 pm
Frank: Let me ask a question. At the margin, who is more likely to get breast implants? Someone happy and satisfied with her looks and her life, or someone unhappy and unsatisfied? I’d wager a considerable sum on the latter, and thus that the surgery/suicide causation runs exactly opposite of your unsupported, unsubstantiated suggestion. I presume the authors of the actual study had enough sense and enough propriety to point out the causation direction problem; I can’t say I’m all that surpsised that you did not.
Frank - January 17, 2008 at 4:16 pm
And Geoff, it doesn’t surprise me at all that on your atomistic, “there is no society” mindset, it would never cross your mind to consider whether individuals’ unhappiness about their looks might be driven by cultural factors (such as a booming cosmetic surgery industry & its advertising) that law and taxation could do something to ameliorate.
geoff - January 17, 2008 at 4:32 pm
Could be. But a) your claim was not based on that relationship, as evidenced by your specific reference to “how long implants last” rather than “a culture of vanity that makes women hate their bodies.” b) At root, however, I’d just like to see some careful analysis and hard evidence rather than hand waving to justify your blithe willingness to curtail our wealth and our freedom for the sake of your hunches about the evils of commerce and the benificence of government. Merely peppering your claims with the words “positional goods” does not qualify, I’m afraid.
Deven - January 17, 2008 at 4:46 pm
Patrick
What are you saying? Because a religion employs a procedure (that only recently has some shown medical benefit) it is somehow necessary? Given your usual comments I am confused here. It is necessary as a cultural issue but not medical. So perhaps you are saying that the procedure shows that culture can dictate procedures but where are you headed with this idea?
Patrick S. O'Donnell - January 17, 2008 at 5:17 pm
I was not at all saying it is necessary, only that it’s silly to view it as another “unnecessary vanity procedure,” given what we know about its origins and justification. I wasn’t thereby attempting to make any normative claim on its behalf. And as an “incidental” remark I did not intend to head anywhere after that….
daisuke nogami - January 17, 2008 at 7:01 pm
Re Frank’s suggestion that cosmetic surgery is responsible for patients’ high rate of depression: as usual, he fails to understand the difference between correlation and causation.
Next thing you know, he’ll propose to shut down all hospitals because more people die there than in any other type of building.
And sure, as we tax cosmetic surgey into oblivion, people predisposed to depression will be immediately cured. And, a propos Frank’s earlier post about teens and designer clothing: as soon as we tax designer clothing into oblivion, teens will stop forming cliques and bullying.
deven - January 18, 2008 at 1:05 pm
Patrick
Thanks for the clarification. I see your point.
best
Deven
Daniel Goldberg - January 18, 2008 at 1:35 pm
Some thoughts on the correlation-causation issue:
Pointing out the everpresent problem of causal direction is not generally sufficient to critique a body of epidemiologic data
Disease causality is always tricky to prove, and of course even robust and persistent correlations typically require the articulation of plausible, evidence-based causal mechanisms.
However, the mere truism that correlation is not causation does not properly imply the correlation is spurious or uninteresting. It’s kind of a generic point that is always kind of obviously, and even non-trivially true, but (1) there are methodological tools for trying to minimze the possibility of mistaking causal direction; and (2) even without those tools significant, robust correlations accompanied by useful causal attributions are extremely helpful from an epidemiologic perspective.
Much of epidemiology, like much social science in general — including economics, I tend to think — relies on articulating correlations, in large part because causation, especially causation of effects produced from a nonlinear, dynamical system like that which produces human health and illness, is often times simply impossible to demonstrate, prove, or disentangle.
Without reliance on such correlations, epidemiology, public health, and many other modes of social science would be impoverished. In part, the importance of finding and evaluating correlations is in part why the fallacy of mistaking causation for correlation is so common. As cognitive scientists have noted, the human brain is far too good a pattern recognition device, such that we see causal patterns were none exist.
So it’s fair to argue that the utmost caution is needed on this front, and to argue that the fallacy is made all too often. IMO, however, it is inadvisable to dismiss or classify as spurious a robust and persistent correlation simply because the precise causal pathways remain somewhat obscure.
Overseas Removal - May 15, 2008 at 5:21 am
Thanks for the clarification. I see your point.
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