Issues in Dental Ethics Issues in Dental Is Cosmetic

Larry Jenson, DDS, MA

AbstractThe ethical ground for restoration (returning a patient to healthy form andfunction) differs from enhancement (usingmedical means to improve appearance).Physicians and dentists who argue thatenhancements improve self-esteem mustreconcile this claim with the fact that theyare not licensed to practice psychology.The extreme views are that doctors either should provide cosmetic services asrequested by patients or they should not.The middle position is that doctors mustretain their fiduciary position of trust based on professional judgment and advocating for patients’ health interests.Patient health always outweighs patients’cosmetic desires.

The rapid rise in demand for cosmeticprocedures in both medicine anddentistry has had a dramatic effect

on the practice of both professions. Bothphysicians and dentists educated in a tradition that emphasizes the use of surgical skills to help people with healthneeds are now routinely asked for proce-dures that have little or nothing to dowith illness. The unmitigated prolifera-tion of “extreme makeover” programs ontelevision and in the print media wouldgive the impression that the medical anddental communities are in full supportof this new deployment of surgical skills. Yet, it is quite possible that theintense public demand has outpaced any thorough examination of the ethics thatare relevant to this change. Perhaps it istime to take a collective breath and try to

Restoration and Enhancement: Is Cosmetic Dentistry Ethical?

Issues in DentalEthicsAmerican Society for Dental Ethics

Associate EditorsDavid T. Ozar, PhDJames T. Rule, DDS, MS

Editorial BoardPhyllis L. Beemsterboer, RDH, EdHMuriel J. Bebeau, PhDLarry Jenson, DDS, MABruce N. Peltier, PhD, MBADonald E. Patthoff, Jr., DDSGerald R. Winslow, PhDPamela Zarkowski, RDH, JD

Correspondence relating to the Dental Ethics section of the Journal of the American College of Dentistsshould be addressed to: American Society for Dental Ethicsc/o Center for EthicsLoyola University of Chicago6525 North Sheridan RoadChicago, IL 60627e-mail: [email protected]

find a way to reconcile this change inpopular opinion about what physiciansand dentists should be expected to provide and the ethical traditions ofthese professions.

This paper will examine the ethicalaspects of cosmetic procedures and try to provide an ethical basis from whichdentists can make sound treatment decisions with their patients. I will arguethat there are indeed times when theethical dentist (and physician) ought tosay no to requests for cosmetic proceduresand I will attempt to provide some practical guidelines for determining such times.

There are several terms and conceptsthat if clearly defined would help thisinvestigation greatly. Unfortunately, termssuch as “health,” “disease,” “normal,”“medically necessary,” “treatment,” “risk,”“need,” and “esthetics” all involve signifi-cant ambiguity and are often at risk ofbeing defined however the user wishes.What counts as a “risk” for one personmay not be the same for another, andwhat is considered a “need” may alsovary greatly within a given population.Nonetheless, I think it is possible to workthrough the general outlines of the

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2005 Volume 72, Number 4

Issues in Dental Ethics

Dr. Jenson is in private practice in San Francisco andis also Associate Professor inthe Division of Clinical GeneralDentistry at UCSF DentalSchool. He may be reached [email protected].

ethics of cosmetic procedures without adefinitive consensus on these terms. Iwill ultimately reject the thesis that sincesubjectivity plays a role in doctor-patienttreatment considerations, it is always thedeciding factor in those cases.

Restoration and EnhancementTo begin, I will take “restoration” tomean the act of returning something (in this case a person) to normal formand/or function. Things in need ofrestoration have a defect of some sortand, with regards to people, these defects go by many names, such as malady, disease, deficit, etc. I will take itas uncontroversial that, whatever theprecise definition of health may be, thetraditional goal of medical and dentalcare has been to eliminate or managedefects and restore people to health(normal form and function), howeverbroad the “normal” limits might be. This is commonly known as healing orcuring or therapy. With regard to plasticsurgery and dentistry, examples ofrestorative procedures include restoringa broken tooth with a porcelain crown,repairing a cleft lip, reconstructing abreast following a mastectomy, andreconstructing a nose following trauma.

“Enhancement,” on the other hand,seeks to take an individual who has nodefect and improve that person’s form orfunction (according to some standardother than health) through medical ordental procedure. Examples of enhance-ment include prescribing steroids orbeta-blockers to improve the perform-

ance of an athlete, surgically altering abody part to improve performance on atask, prescribing amphetamines toincrease job productivity, or any numberof cosmetic procedures (both medicaland dental) that enhance esthetics.

Some will immediately argue thatcosmetic procedures do not belong inthe category of enhancement. Cosmeticsurgeons and dentists are famous forclaiming that patients do indeed have adeficit (unattractiveness, ugliness, etc.)and that cosmetic procedures “heal” theindividual by increasing the individual’sperception of themselves (Christiansen,1989; Leibler et al. 2004). However, JosWelie has convincingly made the case inhis excellent 1999 article that “ugliness”is, on the contrary, not a medical condi-tion at all and procedures that seek to“heal” this condition are outside of medi-cine and dentistry proper (Welie, 1999).Likewise, Eileen Ringel has argued thatthe effects of aging on skin are not a disease and therefore cosmetic skinenhancement is not a therapy or treat-ment in the proper sense (Ringel, 1998).

The problem here is that the advo-cates of cosmetic procedures confusebenefit with therapy. Just because some-thing is of benefit to a patient does notnecessarily place it within the properdomain of dentistry or medicine, whichis the restoration of people to health(normal function and form), i.e., therapy.There is no doubt that people find greatbenefit in tattoos and other body art; butjust because these involve the body itdoes not logically follow that physiciansand dentists should be offering to dothese procedures or that they should be

considered examples of therapy. Manypatients no doubt desire and are madehappy by cosmetic procedures; but this isno argument for the ethical acceptanceof these procedures as appropriate com-ponents of dental or medical practice.

As Ringel states: “When happinessreplaces healing as the goal of medicine,the practice of medicine becomes a com-modity and the medical profession justanother way to make a living” (Ringel,1998). Traditionally, the goal of medicaland dental therapy has been to provide abenefit that addresses a deficit, restoringa patient as much as possible to normalform and function. The suggestion thatphysicians and dentists may provideservices that are outside of the traditionalgoals of both professions should at leastbe ethically suspect. Just because a physician or dentist has the capability toprovide a procedure does not make itethically acceptable to do so. “Therapy”and “treatment” are terms to be usedonly when discussing procedures thathave some dental or medical benefit byrestoring the patient to health or main-taining a patient’s health in the face ofsome threat to it.

Have medicine and dentistry evolvedto the point that this tradition no longerapplies? Perhaps they have. And yet, Idoubt if the subject has had sufficientformal discussion to create a consensusamong practitioners and ethicists. Onething is clear, the sheer prevalence ofcosmetic procedures performed in contemporary medicine and dentistry is

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not a sufficient argument for the inclu-sion of cosmetics within the professions.Moreover, opinion surveys showing thatproviders and patients are “comfortable”with these procedures is a poor argumentas well (Christiansen, 1994). Many mayfeel that in regards to cosmetics “thehorse is already out of the barn.” But mysense is that there is a sufficient level ofuneasiness (at least within the dentalcommunity) that a reasoned ethicalinvestigation may still recover what israpidly being lost everyday.

There is one way in which it mayseem that cosmetic surgeons and dentistsreally do have a good point in sayingthat they are actually providing therapyto their patients. They claim that the cosmetic procedures they perform are“psychotherapeutic.” Poor self-esteemand other psychological maladies areoften “cured” or at least the patient’s situation is significantly improved by giving someone a better “look.”

There are many problems with thisthesis and Eileen Ringel has done anexcellent job identifying them (Ringel,1998). Briefly summarized: There is no strong evidence that cosmetic procedures improve self-esteem. In fact,cosmetic procedures, by focusing onsuperficial attributes of the person, mayonly deflect and defer real progresstoward an authentic acceptance of theperson from which a true increase ofself-esteem will result. Moreover, physi-cians and dentists who perform cosmeticprocedures are not trained to evaluatepsychological and psychiatric disorders,so if this is their rationale for doing cosmetic procedures, they are offeringtherapy without a proper diagnosis or,in the case of dentists, practicing outsidethe scope of practice. In fact, as far asoutcomes are concerned, the evidencethat surgical therapy is an effective treatment for psychiatric disorders (withthe exceptions of body dysmorphic

syndrome and sex reassignment surgery)is thin or nonexistent. Lastly, it is reasonably argued that any patient witha serious psychological deficit requiringtreatment may not be in a position togive an informed consent, and treatingsuch a patient simply on the basis of hisor her request for treatment would beunethical for this reason alone.

The ContinuumWith these arguments in mind, I think it is reasonable to draw a distinctionbetween medical and dental proceduresand cosmetic procedures. Now we must ask ourselves whether dentists and physicians ought to be providingcosmetic procedures at all. And if theanswer to this question is yes, what are the circumstances under which aphysician or dentist is ethically justifiedin performing such services?

We can look at the possible answersto the first question as lying somewherealong a continuum. At one extreme, wehave the position that dentists and physi-cians should not perform any cosmeticprocedures. At the other extreme, wehave the position that physicians anddentists should provide any cosmeticprocedure that the patient asks for aslong as the physician or dentist is competent to provide such services.Somewhere in between these is the posi-tion that physicians and dentists mayprovide cosmetic procedures, but mustnot be merely an agent of the patient;they will sometimes decline to treat basedon their judgment of the situation.

Let’s consider the first extreme. Welie has made the case that cosmeticprocedures are outside of medicine anddentistry proper and thus outside theethics of those professions. People(patients) who decide to allow physiciansor dentists to perform these procedures

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Physicians and dentists who perform cosmetic procedures are not trainedto evaluate psychologicaland psychiatric disorders,so if this is their rationale for doing cosmetic procedures, they are offering therapy without a proper diagnosis or, in the case of dentists, practicing outside the scope of practice.

ought to know that the ethics of the profession do not apply and they can beno more assured of professional carethan they would be at a tattoo parlor.The ethics of the marketplace that anymuffler shop or hair salon follows is theonly ethical standard constraining therelationship at that point. Now if thiswere indeed the case, it is reasonable tosay that there is nothing special abouthaving a physician or dentist providethese services. Just as with tattoos andhair styling, anyone talented enoughand creative enough should be able toobtain a license to provide cosmetic surgery. (In that case, of course, thecosts of these procedures wouldundoubtedly drop and the benefits ofcosmetic procedures would be obtainableby a larger segment of the community.)From the standpoint of the principle of justice, this would necessarily be agood thing.

Doctors and CosmetologistsHowever, most members of society wantmore than justice, low prices, and goodtraining; they demand a certain level ofprofessional judgment and want toknow that, when it comes to surgery ontheir bodies, someone is looking out forthem. Society’s implicit contract withphysicians and dentists expects a securitythat can only come from somethingbeyond skill and training, namely profes-sional judgment in the best interest ofthe patient. It is this fiduciary responsi-bility that distinguishes medicine anddentistry as professions; they are not just businesses. Without this fiduciaryresponsibility there is no such thing asprofessional ethics.

The key aspect of the doctor-patientrelationship is that the doctor is ethicallybound to decline to “treat” a patientrequesting treatment if the risks andcosts of the procedure outweigh the benefits. It is a generally accepted ethicaltenet that patients cannot ask doctors to

hurt them (Ozar & Sokol, 2002;Beauchamp & Childress, 1983). Becauseof this, it is safe to say that people arenot ready to turn over cosmetic surgeryto tattoo artists and others in the estheticsbusiness, however gifted they may be.So, either we license anyone with theability to provide cosmetic procedures, or we bring these procedures into thedomain of medicine and dentistry alongwith the professional ethics that apply to them.

Now let’s look at the other end of thecontinuum. If all cosmetic proceduresare fully within the domains of medicineand dentistry, then patients clearly mayrequest any cosmetic procedure theywish and physicians and dentists whovalue the business may ethically providethese services if they are capable ofdoing so.

Gary Chiodo and Susan Tolle haveaddressed the issue of cosmetics proce-dures in some detail (Chiodo & Tolle,1993). They argue first that there areindeed limits to a patient’s right todemand cosmetic dental services. Brieflysummarized: Dentists have the ethicalduty to weigh the risks, costs, and bene-fits of a given procedure and decline totreat if the risks and costs outweigh thebenefits. The ethical principles of benefi-cence and non-maleficence both supportthis conclusion. But Chiodo and Tollepropose that, if the risks and costs do notoutweigh the benefits, the patient hasthe right to expect the treatment becauseit passes the benefit/harm test that thedentist is professionally obligated toapply. Chiodo and Tolle rightly empha-size the subjective nature of this type ofdeliberation and point out that the per-sonal values of the patients, and thus therationale for their treatment requests,are often different from the values of the

dentist. The significance of risks, costs,or benefits varies from patient to patient.Chiodo and Tolle argue that a dentistshould not impose his or her values onthe patient unless a clear case can bemade that the proposed treatment hasunacceptable risks or will, in fact, resultin harm to the patient. They go on to say,however, that dentists always have theright to refer to another practitioner ifthey are “uncomfortable” doing a proce-dure they would not choose for themselves.

There are two points to be madehere regarding Chiodo and Tolle’s position. First, the word “treatment” isused to describe cosmetic procedures.“Treatment” suggests that there is somedental health benefit received as a resultof the procedure. We have already estab-lished that there is no health-relateddental benefit (no goal of restoration) inenhancement procedures, so this use ofthe word “treatment” stretches its mean-ing significantly. When no health-relateddental benefit is to be had, normal considerations for balancing risks, costs,and benefits may not apply. More on this point below.

Second, as I have argued previously(Jenson, 2003), if a procedure’s risks and costs do not outweigh the benefits,the dentist must ordinarily provide thetreatment if he or she is capable.Otherwise there is no real ethical weightto patient autonomy.

Chiodo and Tolle are in alignmentwith this; and other bioethicists wouldagree that the normative picture of thedoctor-patient relationship as a paternal-istic or guild-based cannot be accurate(Ozar & Sokol, 2002; Kirkland & Tong,1996). But the fact that the doctor-patientrelationship should not be paternalisticdoes not require us to accept the otherextreme of our continuum where thedoctor is merely an agent of the patientand must do whatever the patient asks.

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With just a little reflection and a fewexamples, the case can be made that thisextreme position does not accuratelydescribe the ethics of enhancement procedures. Consider the case of a personwho would like to have his front teethfiled down to sharp points for eitheresthetic or cultural reasons. While wemight make the case that the patient values this procedure highly, we wouldbe hardpressed to find a practicing den-tist who would agree to this procedure.Similarly, we would be hardpressed tofind a physician who thinks it is a wisechoice to give an otherwise healthy athlete a prescription for steroids. Inboth cases, the harm or potential harmto the patient seems to conflict withsome deeply held sense of what it meansto be a dentist or physician. It simplydoes not make sense to create an ethicalparameter for the doctor-patient rela-tionship that has implications that nodoctor could support. We need to seeksome sort of reflective equilibrium thatis both rational and realistic.

Having looked at the extremes, let’snow consider a middle position. Thisposition states that cosmetic proceduresmay be done by dentists and physicians,yet it also holds that there are timeswhen the physician or dentist must say“no” to an enhancement request. Howare we to define this position and locateit along the continuum? While it may bedifficult to delineate this point in specificinstances, I think we can at least estab-lish some general guidelines.

The first point to stress is open com-munication between doctor and patient.Weighing risks, costs, and benefits todetermine a course of treatment in theproper sense is, by anyone’s assessment,not a mathematical process. The processalways involves the judgment and valuesof both doctor and patient. A differentoutcome from these deliberations isalmost to be expected with different doctors and different patients. However,the fact that these deliberations involvesome aspect of subjective values does notmean that they are inherently irrational;reasonable people can come to differentconclusions and parties who disagree on what is best may still agree preciselyon what is unacceptable. A judiciousconsideration of clinical experience,research studies, and patient preferencesis ethically demanded of the doctor andcan lead him or her to a reasonablygood and ethical treatment plan for aspecific patient.

This dynamic process, this interac-tive style of doctor-patient relationship is crucial to the ethical treatment ofpatients (Ozar & Sokol, 1994). And itmust be part of the relationship betweendoctor and patient when cosmetic procedures are under consideration.Ultimately, both patient and doctor have rights; neither gets to dictate thetreatment at all times and each has theright to decide not to participate in aprocedure, the patient at anytime andthe doctor under certain circumstances(Jenson, 2003).

Second, having already establishedthat enhancement procedures are not“treatments” per se, it is fair to ask thenif the same ethics apply to decisionsbetween doctors and patients about cosmetic procedures as they apply totreatments proper. I propose that in thecase of cosmetic procedures, it is simplynot important to the dentist’s ethicaldecision that the patient thinks the

procedure would be beneficial. The valuesat work in patients’ cosmetic decisions in the dental office do not differ from thevalues at work in other areas, far outsideof the domain of dentistry and medicineproper, including tattoos and hairstyling. People do, of course, place greatbenefit in some of these things; but whatsignificant difference is there betweenpeople’s valuing of cosmetic medical anddental procedures and their valuing oftattoos or hairstyles? The proposal hereis that we have to say that all cosmeticprocedures are simply a benefit to thepatient with no hierarchy of value inrelation to health, which is the focus ofdental and medical decisions in theproper sense. As such, they are irrelevantto the doctor’s deliberations as towhether or not he or she should agree todo the procedure. In practice this willmean that the threshold at which thedoctor may say “yes” to a procedure risessignificantly with a cosmetic procedurebecause it involves no health benefit tobe weighed against the possible risks andharm of the procedure. What is importantto the doctor’s deliberation, then, iswhether or not the procedure presents asignificant harm or potential for harmto the patient’s oral or general health.

For example, while it may be justifi-able to expose a patient to the risk ofdeath by general anesthesia (one in tenthousand cases) to obtain a medical benefit (e.g., removing a brain tumor), it is unjustifiable to expose them to thesame risk in order to remove the fatfrom their thighs. For a dental example,a dentist who places a gold crown on atooth that has no need for restoration,simply because the patient sees anesthetic benefit, would be practicingunethically given the fact that there is a

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risk (one in one hundred) that the pulpof the tooth would be damaged in theprocess. Another common dental exam-ple would be the placement of porcelainveneers. If the veneers are intended toovercome some defect, (say, deterioratingrestorations) the benefits of the procedureare more restorative in nature and maythen be worth the relative risks andcosts. Placing veneers to take a patientfrom a Vita shade B3 to B1 on the otherhand, is clearly an enhancement proce-dure and may be difficult to justify giventhe attendant risks and costs. As an alternative, bleaching teeth has few ifany risks and may therefore be ethicallyjustified for the patient who has stained teeth.

The proposal here is that, if there is no health-related benefit to justify it,the dentist may not ethically perform aprocedure with any significant risk ofharm to the patient. If an enhancementprocedure can be done without signifi-cant hazards, a dentist or doctor mayagree to a patient’s request. (At no time,of course, is the doctor justified in providing a procedure if it is beyond hisor her capabilities.) Patient autonomynever outweighs the patient’s health(Ozar & Sokol, 2002), and so the rangeof ethically acceptable procedures available for a patient to choose fromwill thus be significantly curtailed whenit comes to cosmetic procedures.

Is it possible to maintain this distinc-tion between these two ethics (patternsof valuing), one for regular dental proce-dures and one for cosmetic procedures?Can we really split professional ethicsand say that some procedures demandone set of behaviors and another proce-dure some other? While it may seemcounterintuitive initially, I propose thatthis is the case. Keep in mind that the onlyreason to include cosmetic procedures inthe domain of medicine and dentistry isthat the community thinks they ought to

be there for its own protection. But thecommunity cannot have it both ways: itcannot both demand that doctors makeall of these procedures available andthen not bring their professional judg-ment and professional duties to bear inspecific cases—especially the duty not toharm, and to permit harm only in theinterest of even greater health benefit.This would leave dental practitioners (at least the conscientious ones) in animpossible position. Distinguishingesthetic procedures from health relatedtreatments in this way produces a work-able compromise that is superior toeither of the extreme positions.

In the future, physicians and dentistsand the community will have to decide ifenhancement procedures will eventuallybe part of medicine and dentistry properand that health will mean more thanrestoring a person to normal functionand form. (There are signs that we maybe moving in this direction: see CarlElliott’s 2003 book, Better than Well).Until then, many of the cosmetic surgeriescurrently performed by physicians anddentistry simply cannot be supportedethically. This is not in any way a judg-ment on the values of the people whoseek these procedures. People, ultimately,have the right to decide what they dowith their bodies. They cannot, however,expect that a doctor should take part inthat choice and contribute to the harmthat these choices may bring. Peoplemust accept that there are limits to whattheir doctors can ethically provide; and if they desire more than this, theyshould seek those who are not bound byprofessional ethics. Caveat emptor. ■

ReferencesBeauchamp, T. L., & Childress, J. F. (1983).Principles of Biomedical Ethics. New York:Oxford University Press.Chiodo, G. T., & Tolle, S. W. (1993).Requests for treatment: Ethical limits oncosmetic dentistry. General Dentistry, 16-19.Christiansen, G. J. (1994). How ethical areesthetic dental procedures? Journal of theAmerican Dental Association, 125, 1498-1502.Christiansen, G. J. (1989). Esthetic dentistry and ethics. QuintessenceInternational, 20, 747-753Jenson, L. E. (2003). My way or the high-way: Do dental patients really haveautonomy? Journal of the AmericanCollege of Dentists, 70, 26-30Kirkland, A., & Tong, R. (1996). Workingwithin contradiction: The possibility of feminist cosmetic surgery. The Journal ofClinical Ethics, 7 (2), 151-159.Liebler, M., Randall R. C., Burke, F. J. T., etal. (2004). Ethics of esthetic dentistry.Quintessence International, 36 (6), 456-465.Meningaud, J-P., Servant, J-M., Herve, C.,Bertrand, J-Ch. (2000). Ethics and aims ofcosmetic surgery: A contribution from ananalysis of claims after minor damage.Medicine and Law, 19, 237-252.Ozar, D. T., & Sokol, D. J., (2002). Dentalethics at chairside: Professional principlesand practical applications, (2nd ed).Washington, DC: Georgetown UniversityPress. Ringel, E. W., (1998). The morality of cosmetic surgery for aging. Archives ofDermatology, 134, 427-431.Welie, J. V. M. (1999). Do you have ahealthy smile? Medicine, Health Care andPhilosophy, 2, 169-180.

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