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From yesterday's piece:
Don't look now, but a woman in Ohio has a new face. And the world has a new kind of medicine: socially necessary surgery.
The operation, announced yesterday at the Cleveland Clinic, was a face transplant from a corpse. ... Doctors replaced 77 square inches of the patient's face, from her eyelids to her chin.
More here.
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Eight months ago, I thought I saw a silver lining in this recession. Now it's looking more like scar tissue.
The silver lining, I thought, was that cosmetic surgery was taking a financial hit:
A breast implant company disclosed a decline in surgeries late last year; a laser eye-surgery firm has lowered its forecast based on a similar trend early this year. A professional breast augmenter frets that in January and February, business for some of his colleagues was off 30 percent to 40 percent. ... More effectively than any bioethicist, the recession is reminding people that cosmetic work isn't medicine. "While healthcare spending as a whole has traditionally moved independently of the economy—a safe haven—that really isn't the case with plastic surgery," a financial analyst tells the Times. In the new, sobered economy, the paper reports, some cosmetic doctors are diversifying into "reconstructive surgery for cancer patients and others that is covered by insurance." Insurance!
Say what you will about coverage-denying bean counters, but they do enforce the essential priority of urgent procedures over elective ones. In a health-care industry controlled by tight budgets and insurers, you might even see the cream of the med-school crop shift back to the kind of work that keeps people alive.
That was then. This is now: The Associated Press reports,
Johnson & Johnson said [Dec. 1] it would buy Mentor, a maker of cosmetic products and breast implants, for $1.07 billion, a move that would help the drug maker become a major player in cosmetic and reconstructive surgery. Analysts said Johnson & Johnson was paying "a giant premium" for Mentor, which makes MemoryGel breast implants, liposuction equipment and skin repair products. ... "It's a good space for J.& J. to get bigger in because it's a space with the least cost-control pricing pressures," as patients, rather than insurers or government health programs, generally pay for cosmetic surgery, said Erik Gordon, associate dean and head of biomedical industry programs at Stevens Institute of Technology.
In other words, the increasing power of insurance gatekeepers and cost controls, driven by the recession, might drive some companies out of health-oriented medicine and into cosmetic procedures. The inability of middle-class people to pay for boob jobs doesn't mean providers have to shift their focus to real medicine for the middle class. Maybe they'll shift their focus instead to boob jobs for the rich.
True, the rich are a smaller market than the middle class. But if the cost controls in real medicine are too tight, providers can make up in profit margins what they lose in volume. So, as we're revising our health-care system, let's try not to drive too many doctors and health companies out of real medicine. They might have something less important to do.
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Six years ago, President Bush's bioethics council opened its inaugural meeting with a discussion of The Birth-Mark, a Nathaniel Hawthorne short story. Council member Bill May summarized the plot, in which a scientist "loves his wife but kills her in the attempt to remove her single imperfection, a birthmark on her left cheek." For nearly an hour, the council sat around debating what the mark symbolized.
Today, the council has run its course—the Obama administration will probably replace it with a more sympathetic panel—but the news has come back to birthmarks. The Vascular Birthmarks Foundation and the Vascular Birthmark Institute of New York just held their eighth annual Vascular Birthmarks Conference, at which dozens of families met with doctors to discuss surgery and other medical options. The New York Times reports from the conference:
"We can no longer accept that a child can go through life being severely disfigured, and accept that as their lot," said Dr. [Milton] Waner, the co-director of the Vascular Birthmark Institute. "Something needs to be done, and I believe that every child has the right to look normal." ... Much of the concern, for many families at the conference, was financial. Doctors said insurance providers frequently refused to pay for the treatments, classifying them as cosmetic surgery. "Their definition of cosmetic is very broad," Dr. Waner said. "This is not cosmetic."
Strictly speaking, Dr. Waner is incorrect. Disfigurement per se is cosmetic. Merriam-Webster's medical dictionary, on which the National Institutes of Health rely, defines cosmetic as "of, relating to, or making for beauty." It defines cosmetic surgery as "correcting defects especially of the face." One question is whether insurers should cover such procedures. Beneath that question lies another: Do children need them?
When you read about these kids and the abuse they sometimes endure for looking unusual, your heart goes out to them. One mother tells the Times about a boy who walked past her son and said, "Look at your face. You look ugly." But which is the problem, the birthmark or the bad attitude? Something needs to be done, but is it surgery? Is every child entitled to "look normal"? Or is he entitled to respect regardless of how he looks?
As it happens, surgery for the kid who was called ugly is a no-brainer. That's because his disfigurement had functional effects, enlarging his tongue so he couldn't speak intelligibly. Dr. Waner and others who take on such cases pro bono are doing noble work. But the quest for normality can extend to iffier cases. The Times describes a baby at the conference who "has a circular, purple mark on her forehead about the size of a nickel." Such defects, known as hemangiomas, "often disappear or shrink in 10 to 12 years, but they can have a social and psychological impact—on children in particular, who must live with the stigma of looking different." Is that a good reason for surgery?
I'm not saying kids with purely cosmetic defects don't suffer. They do. But their suffering isn't medical. It's social. Cosmetic surgery changes an otherwise healthy body to fit culturally imposed aesthetic standards. If a purple mark on your forehead is too much to bear, what about male breasts? What about a flat female chest? How far should we extend the "right"—and, implicitly, the obligation—to look normal?
We had a vascular birth mark in my family. It was considerably bigger than a nickel. In time, it subsided and vanished. The child who was born with it had something more important than the right to look normal. She had the right not to.
P.S. It looks like our "discuss" link is still broken, so here's a handmade link to the HN fray in case you'd like to join the discussion: http://fray.slate.com/discuss/forums/2100253/ShowForum.aspx.
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Two months ago, I celebrated what seemed to be an emerging recession in cosmetic surgery. That assessment was based on anecdotes and sketchy data from Reuters and the Los Angeles Times. The good news, I argued, was that the rough economy was reminding people which medical procedures were necessary and which weren't. It was also forcing doctors to shift from cosmetic profit back to the real work of promoting health.
Last week, a follow-up Reuters story cast doubt on the trend. Britain's biggest cosmetic surgery company reported a 35 percent increase in procedures in less than a year, led by a 59 percent increase in tummy tucks and a 40 percent increase in breast augmentations. A company spokeswoman opined:
It's interesting to see what people cut back on during a credit crunch. Research among our patients has shown that despite cutting back across all other areas ... people aren't cutting back on money they spend on themselves. For many who are undertaking an abdomnoplasty this is something they've planned for years. For this reason, they're unlikely to want to now put this off and instead they consider their procedure to be an investment.
How depressing. I know it's now standard practice to peddle every product or service as an investment. But cosmetic surgery? It's not health. It's not even disposable property.
Now further data are backing up the original trend reports. Natasha Singer of the New York Times says the two-year waiting lists of a few years ago have dried up:
Earlier this month, this reporter, using a script, made identical anonymous calls to the offices of 48 prominent plastic surgeons in makeover meccas like Orange County, Calif., and the Upper East Side of Manhattan, asking staff members about the earliest possible appointment dates for consultations and cosmetic surgery. I selected plastic surgeons who have appeared regularly on television, or in glossy magazines, or who are listed in the 2007 edition of "America's Top Doctors" ... [A]bout 90 percent of the doctors' offices offered consultations in three weeks or sooner; and about 94 percent offered surgery dates in June or July.
More broadly, total cosmetic surgeries are still 3 percent below the levels of eight years ago.
Why the shrinkage? Because money is tight. "A survey in April and May of more than 600 plastic surgeons, by the American Society for Aesthetic Plastic Surgery, reported that almost 53 percent said the downturn in the economy has had an adverse impact on plastic surgery practices," Singer reports. Data show that the recession hasn't driven clients out of the cosmetic market altogether. But it has downshifted their spending from expensive surgeries to Botox and other cheaper nonsurgical procedures.
One plastic surgeon tells Singer that in previous years he had clients "refinancing their homes and using them as A.T.M.s" to pay for breast augmentations and liposuction. Ponder the insanity of that: risking the most expensive of life's three traditional needs—food, clothing, and shelter—for pure vanity. And then, when you can't pay the mortgage, we're supposed to bail you out? And your surgeon calls what you did an "investment"?
Fortunately, not every doctor has lost perspective. When asked to explain the drop in clientele, another plastic surgeon tells the Times: "We are a luxury item. People want us, but they don't actually need us."
Exactly. Skip the boob job. Keep the house.
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New piece this morning on the recession in cosmetic surgery. As I was writing it, I realized how completely it dovetails with the previous post about nipple rings. Both argue for a distinction between elective and necessary procedures. That's an old theme of bioethics, and it suits my conservative streak. Or maybe it's not conservative; maybe it's just hard-nosed. I do think some things in life are way more important than others, and both abundance and indulgence can make you forget the difference.
On the other hand, I don't want to become cranky. When I think of cranky, I think of Bob Dole, or at least Dan Aykroyd's caricature of Bob Dole, muttering bitterly about how easy some people now have it. In general, there's nothing inherently wrong, and there's usually a lot that's wonderful, about making things easy that used to be hard. That's certainly true of medicine. It's just important to keep in mind the relative value of the things achieved and the relative importance of effort in making a particular result worthwhile.
I remember going to a transhumanist conference a couple of years ago. For those of you who don't know them, transhumanists are people who believe in the technological transformation of humanity into something greater. When I first left politics to cover this beat, I took a pretty conservative line on bioethics generally, and the transhumanists sounded pretty fruity to me. Well, they're still kind of fruity. But they certainly are interesting, if you treat them as a voice in the public dialogue rather than as a threat to dictate future policy and destroy human nature (whatever that is). And the more you listen to their assault on conservative assumptions, the more you find yourself asking questions about the way things are and whether they have to be that way. Those are good questions to ask.
I'm still trying to find my own blend of progressive and conservative, liberalism and discipline. Nipple rings? Just not that big a deal, either way. Face lifts? Ditto. But sex-reassignment surgery? That's pretty fundamental to who you are, and I'm inclined to listen to people who have lived in what they profoundly experience as the wrong body. I'll keep thinking about these things, and I'll try to keep my mind open to all ideas, including the idea of limits.