Even in those stories constructed around a single participant, one never gets the feeling that the patient on a reality show has all that much input into the treatment plan. It is unsettling to watch a patient undergo nine hours of surgery that includes procedures she did not ask for. It is equally dismaying to watch the even more common scenario in which the patient relinquishes her autonomy and the doctor accepts, often without batting an eye, the unshared role of decision maker. The viewer can sense the nervous excitement of the patient who says, after listening to the doctor explain what is to happen, “Whatever you say doctor; I am in your hands.” It is hard to image a worse message to send to potential patients in the viewing audience. (When I hear those words in my practice, I always feel that the patient may not really understand what is proposed and that we need to back up a bit.) Yet this message of blind faith and miracles has sent many a customer to the local cosmetic surgeon’s door.
Physicians watching these shows often comment on the eerie sensation of watching multiple episodes in which one technique seems to “fit” all candidates. Some patients have undergone procedures that to the educated eye look like shortcuts to fit the schedule rather than the best operation for the patient’s condition. In fact, participants on a cosmetic surgery reality show are only “allowed” to undergo procedures from which they can be completely recovered within the six- to- eight- week framework of the make over “incarceration.” Thus treatment is tailored to fit the show rather than the patient, hardly in keeping with putting the patient’s best interests fi rst. Others have procedures that produce dramatic Hollywood results but more than likely look “overdone” in the cold light of day, after the thrill of the experience has subsided.
A reasonable physician might question the televised medical decision making itself in some instances and wonder if it too has fallen victim to the pressure to create good stories. For instance, disturbing as it is to watch a cosmetic patient relinquish decision making to a doctor, it is just as upsetting to witness a surgeon acquiescing to unreasonable demands by a patient, apparently against his better judgment. In another example, we might ask if it is really necessary to perform an eyelid lift on a twenty-one-year-old. One patient lost 23 pounds in twenty days postoperatively; another had dropped 30 pounds three weeks after surgery. Should a physician be sanctioning rigorous weight loss and exercise regimens with a compressed time frame just weeks after so much major surgery?
More Is Better
By definition applicants do not get chosen for “extreme makeovers” if they only want to have one procedure, but they can still be on the show if they only need one thing done because “need” is irrelevant. The volume of procedures undergone by many patients on reality shows baffles and dismays many physician observers. The shows themselves downplay the number of procedures to which participants are subjected—many of the procedures actually performed are not identified until the operating room scenes or during the tally at the end of the story. Watching these shows one gets the impression that every feasible intervention is proposed to every participant. This feature alone redefi nes the role of a physician in the preoperative counseling phase in a way that many observers fi nd unacceptable. Leaving Out the “Care” in Medical Care Ethical concerns about the treatment of patients on television are not unique to critics of cosmetic surgery reality shows; the widespread use of private stories in the public forum of television raises numerous questions about ethics in broadcasting. Certainly, in the era of HIPAA (federal patient privacy legislation), it is ironic that so many people are willing to expose themselves (literally) to the world. Some scholars speculate that this is a neat turning inside out of the chilling concept of the near-universal presence of cameras foreseen by George Orwell in 1984.6 Instead of living in a society where surveillance is unavoidable, reality show participants mirror citizens with Web cams in their homes, voluntarily performing for whoever is watching. Still, the fl yon- the-wall format is a troubling phenomenon and begs the question whether individual participants, particularly patients, and their private stories are being inappropriately manipulated for public entertainment and commercial benefit through the pro cess of surveillance, analysis, and public display.
Invariably missing from all reality television programs is respect for the privacy and dignity of the participants, who are burdened with the physical and psychological stress of undergoing major surgery designed to result in a permanent change in appearance. The producers of cosmetic surgery reality shows make no effort to hide the fact that many participants ride an emotional roller coaster during their experience. If the patients’ apparently genuine displays of emotion are encouraged or somehow choreographed for the camera, then surely the producers and other members of the team have overstepped the ethical boundaries that should protect patients from unwarranted intrusions into their privacy. If the emotions are real and merely captured because of the constant presence of the cameras, then some of these patients are clearly in need of more emotional support than is being provided to them. In either case we appear to be viewing a much degraded method of the care and nurturing of patients whom medical professionals are morally and ethically bound to protect. The argument that these patients have been fully informed about the show’s expectations of them is specious because a patient in the pro cess of undergoing or recovering from general anesthesia and surgery is impaired and particularly vulnerable to anxieties and fears that do not apply to other reality show scenarios. It is inevitable that the presence of cameras, film crews, producers, and a host of other strangers irrelevant to the medical care in progress distorts and enhances the anxiety that naturally arises from the experience of undergoing major surgery. The contest aspect of shows like The Swan—the public embarrassment of participants as they are judged and found wanting—and the disgrace of producers requiring patients to undergo surgery and recovery in enforced isolation from families and friends, with only strangers with their own agendas to encourage them, are the antithesis of compassionate medicine. Follow-up stories on cosmetic surgery reality show participants have been few, but several have uncovered signifi cantly detrimental downsides to patients’ encounters with the reality show machine that remind us of the tales of destruction wrought on some recipients’ lives by winning a big lottery pot—coworker resentments, family strains, distressed children, and gradual dissipation of the glamour as real life takes hold once again. It appears that, like lottery winners, some makeover recipients are unprepared to cope with the potentially profound life changes that may accompany the physical ones.
Cosmetic surgeons have long known that undergoing a radical change in appearance over a short time is a major emotional stress, even if the physical results are pleasing. Reality shows do not acknowledge or take responsibility for guiding participants through this difficult period. “If you need us, by all means come to us,” a Time magazine article quoted Extreme Makeover producer Maria Brodsky. “But will we send doctors out to you and have them call you every week? No, because there is no need.”7 How she can know that just because the patients don’t call her, it is a mystery. When asked about contestants who seemed to be distraught, The Swan’s producer and contestant coach Nely Galen was quoted in People as saying, “Yeah, it was tough, but it’s also hard being on Survivor . . . That’s too bad. On our show, you don’t walk away with nothing, you walk away with $250,000 worth of services from day one. And that’s the price you pay.”8 In other words, you got a prize, so we don’t have to treat you like a real patient. The producers usually justify this poor treatment by stating that participants are told all the risks, implying that responsibility stopped with the telling. The emotional and psychological effects of radical makeovers are hardly limited to the recipients. Viewers might reasonably question, for example, the portrayal of a mother of very young children who leaves her family for two months, supposedly allowed only the occasional phone call, in order to undergo an assortment of cosmetic procedures, none of which under normal circumstances would have required her to be away from her kids for more than a few days or a week, all in the service of the dramatic imperative of a television show. It is incredible—medieval, really—that the producers would inflict such a demand on a family, yet these are the “rules” for those wishing to participate in this fantasy. Their family members, however, may experience the fairy tale differently. One patient’s husband declared, “The biggest difference was when she got her hair done” and another’s young child said wistfully, “I liked my old mom better.”
The Public Interest: The Impact of Entertainment Medicine on Viewers
One might argue that cosmetic surgery reality shows appear to be promoting a social hierarchy based on manipulated, celebrity-driven forms of appearance in which normal or average-looking people are not good enough and therefore should go to great lengths, expense, and risk to change. The suggestion is that if you are not movie star– gorgeous but not unhappy about it, there is something wrong with you. Likewise, if a celebrity is caught looking normal, he or she is deficient. A reader recently wrote to the Q & A column of a popular magazine with the following complaint: “With high- defi nition TV, I notice that aging actresses like Heather Locklear have fl awed skin. Can they do anything about it?” One can reasonably presume that an actress like Ms. Locklear makes a regular effort to maintain her complexion; however, she is, unfortunately, imperfect and requires the assistance of smoke-and-mirrors professionals to “fix” her fl aws. Underlying the absurdity of a celebrity appearance–based social hierarchy is the fraud exemplifi ed by I Want a Famous Face. Not only is it impossible to make someone look exactly like someone else, but the iconic image of a celebrity in many cases is the end result of cosmetic interventions, the attentions of personal trainers and chefs, the private indulgence in unhealthy practices like smoking and poor eating habits for the purpose of weight control, not to mention highly skilled makeup and hair artists and photo editing. The public knows this but doesn’t want to believe it.
The public should also be concerned about the other false messages about cosmetic medicine that emanate from entertainment sources: Cosmetic surgery is pain and risk free; multiple simultaneous procedures and long operations are no big deal; procedures entail little inconvenience or time off work; intensive, short-term therapy or “life coaching” can solve a variety of problems; marriages can be saved; job offers will flow in; physical fitness and stamina will improve; basic personality traits can be altered; the featured product Ethics and Cosmetic Medicine 95 and services are superior; providers are motivated to appear on shows and display their expertise primarily by a desire to perform a public service.
In the end, cameras or no cameras, the people who are selected to participate in these shows become patients, and they enter into a covenant with representatives of the medical profession in which the public imbues a trust. That solemn covenant cannot and must not be redefined as entertainment. Other observers have been blunter. Margaret Sommerville, founding director of the McGill Centre for Medicine, Ethics and Law (McGill University, Montreal, Canada), says there is “something obscene” about the phenomenon of cosmetic surgery reality shows. “[They show] a fundamental disrespect for the people in the shows and for humanity in general.”10 Do People Respect Their Doctors Anymore? Despite the decline in absolute physician authority during the past century, patients still tend to trust their physicians with a certain degree of blind faith, automatically granting them respect and assuming their professionalism. For the most part, media depictions of physicians, especially cosmetic medical providers, do not encourage this trust. The two image bogeys are the soulless entrepreneur and the godlike wizard. The first has already been addressed. As for the second, it is well known that cosmetic surgeons are often described, sometimes by themselves, in hyperbolic terms that defy gravity. The compelling idea of the “surgeon as artist” first sidesteps the fact that human bodies are not made of inert substances to be molded and re-created according to the surgeon’s personal aesthetic vision. The second trap that the “surgeon as artist” idea sets for us is the search for the holy grail, that universal and perfect form that does not exist, yet the application of individual surgeons’ concepts of it has led to untold numbers of obvious, unaesthetic, “done” results. To be sure, there are many surgeons in all specialties who are brilliant, creative thinkers and superb craftsmen and women, but beautiful results come only from excellent judgment, great skill, and even better luck.
If the greater public consciousness settles on the image of physicians as profit-minded businessmen before compassionate professionals, supersized egos before advocates, we physicians will have lost a public relations battle that will take more than one lifetime to undo.
ETHICS AND PROFESSIONAL ORGANIZATIONS
Some major medical organizations, such as the AMA, the ASPS, and the ASAPS, have written codes of ethics that address issues of physician behavior. The AMA is one of the few organizations to make its ethics code available to the public (see Resources). Those organizations also have mechanisms by which they can warn or censure member physicians who do not adhere to professional standards of conduct. However, just as physicians and other practitioners are not obligated to join professional organizations, they are not legally bound to observe ethical principles.
Enforcement of ethics rules by professional organizations is variable—in the case of cosmetic medical care it seems that, for the most part, organizations have neither the will nor the means to ensure that all of their members adhere to ethical principles. One can read the code of ethics of the AMA and contemplate whether its principles of respect for human dignity and rights; provision of relevant information to patients, colleagues, and the public; recognition of a responsibility to the community and to improved public health; and regard for the responsibility to the patient as paramount are upheld on cosmetic surgery reality shows. The ASPS code of ethics, a casual observer of the cosmetic medical landscape might be surprised to learn, is quite detailed on issues of misrepresentation and prohibits the organization’s members from exploiting patients’ anxieties and vulnerabilities. Lest one demurs that physicians are not ultimately responsible for the events on television shows, we must remember that these shows would not exist without surgeons to perform procedures and that at least one show advertises its stamp of approval from major plastic surgery organizations.
The AMA, in perhaps the best position to address issues that affect physicians from multiple specialties, has indicated some intent to address the ethical issues raised by reality shows. In a press release on December 4, 2004, the AMA House of Delegates stated, “Reality television shows that depict surgery should not minimize the seriousness and risks of surgery and distort patient expectations.” Clearly not certain that his organization has the clout to tell television producers what to do, yet wishing to remind physicians of their fiduciary duties to patients and the public, a trustee stated, “It is a physician’s ethical responsibility to accurately and openly discuss the risks and benefits of any treatment, including surgery. These reality shows need to follow the same ethical principles.” At that time the AMA announced a plan to formulate an opinion on physician participation in television entertainment programs. The panel assigned to develop the policy, the Council on Ethical and Judicial Affairs, has already issued a recommendation on protecting patients’ privacy in the presence of outside observers, and that recommendation has been formally adopted by the AMA: “Physicians should avoid situations in which an outside observer’s presence may negatively infl uence the medical interaction and compromise care.” As it has already been made abundantly clear that national television cameras in the courtroom affect the behavior of all of the participants in a trial, so must cameras in the exam room and the operating room inevitably influence the medical encounter.
THE PRICE OF PATIENT AUTONOMY
Ostensibly in the service of individual patient autonomy, our society has, by way of relaxed governmental regulations, allowed the health-care industry to target consumers directly in much the same way that other capitalist markets operate. As Tauber points out, some think that medical care should be considered a commodity; patients/consumers should be given more information and allowed to exercise free choice among health care options, which in turn should lead to better pricing and quality of care.Unfortunately, in the case of cosmetic medical care and many other areas of medicine, the ability of providers and manufacturers to market directly to consumers has led to the predominance of message over medicine, sales over science. Against the blaring background of commercialism and the steady erosion of patient care values, prospective cosmetic patients must rely on their own efforts to educate themselves about their medical care options, as will be discussed in the chapters that follow.
Tags: cosmetic surgeons, extreme makeovers, federal patient privacy legislation, HIPAA, major emotional stress, Medical Care Ethical concerns, reasonable physician