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Why is the debate about removing and replacing faulty or potentially faulty breast implants causing such a storm? At one level the issue is straightforward – a product which was thought to meet a certain safety standard does not in fact do so, and the manufacturers seemed to be fully aware of this. The checks and balances that are put in place to avoid the use of sub-standard products failed to pick up what appears to be deliberate deception on the part of the manufacturers, suggesting that there is a need to review these regulatory procedures. The company, meanwhile, has gone out of business and so the question of who pays, and for what, needs to be settled.

As well as concerns about the adequacy of the regulatory systems, the debate concerns questions about accountability and responsibility. If I buy a product (in this case implant surgery) in good faith, believing that certain standards will be met, it seems reasonable that this should be replaced if it is shown to be sub-standard or even dangerous. If the person who sold me this product also did so in good faith, it seems reasonable that they should also seek redress from those responsible, and it may need a legal judgement to determine exactly where this responsibility lies. In this respect, it seems that the moral case for expecting those clinics and clinicians who used sub-standard implants to remove and replace them might be stronger than the legal case. This moral responsibility is underpinned by the concept of trust – a powerful and important feature of the relationship between doctors and their patients. I trust my doctor to avoid harming me, and this trust is undermined when potential harms are revealed. This leaves a problem: what should be done about those clinics who don’t feel that there is a moral imperative for them to remove and/or replace these implants? Should the NHS step in?

Sympathies vary here, and some of the argument seems to rest on the concept of clinical need: was there a medical reason for the surgery in the first place? Women who have had breast implants following surgery for cancer were more likely to have had this carried out by the NHS, whereas women who opt for breast augmentation (as it is known) for cosmetic reasons, are more likely to have been treated privately. Is there are possibility then, that those women who have been treated for breast cancer are seen as more deserving of their cosmetic surgery than those women who choose surgery in order to improve their body image? Few would dispute the enormity of the impact of mastectomy – the removal of the breast as a treatment for cancer. But interestingly, the reasons that this loss is so difficult for some women are the same set of reasons that lead some women who haven’t had cancer to opt for breast surgery. Simply put, the way we look, and the way that we feel about how we look, matters for many people.

Furthermore, the way that we feel about how we look isn’t under the control of the individual. It’s no secret that women’s breasts are used to sell everything from newspapers to cars, and the symbol of breasts as representing femininity is so powerful that female bodybuilders will undergo breast augmentation to enlarge their breasts, despite confronting the norms of femininity in other ways (Bavington 2008). Feeling attractive, according to the standards of attractiveness that prevail, contributes to people’s confidence, and femininity is one of these standards. This confidence is not mis-placed: social psychologists tell us that being perceived as attractive according to the standards of the day has been shown to increase a person’s chances of success in many walks of life, for both women and men.

The medical profession itself reinforces these standards. The condition of micromastia, or very small breasts, was first identified as a condition which warranted surgical intervention in the 1950s, and in the 1980’s the American Society of Plastic and Reconstructive Surgeons campaigned to have such conditions recognised as a disease, and lobbied for breast augmentation to be covered by medical insurance, claiming that small breasts ‘…are really a disease which result in the patient’s feelings of inadequacy, lack of self-confidence, distortion of body image and a total lack of well-being  due to a lack of perceived femininity’ (cited in Ferguson, S 2000 p71). Interestingly, the reverse is true for men and the condition of gynaecomastia, or excess breast tissue in men, is also recognised as a condition warranting medical intervention, when the embarrassment experienced by the man affected is seen as interfering with his well being.

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So, there are numerous issues here, and while questions about the adequacy of the regulatory procedures are important, and the question of who should pick up the bill for removing potentially faulty implants needs settling, the wider questions about why so many women opt for breast enhancing surgery are much more complex, and not as straightforward as they might at first appear. This in itself suggests caution when judgements are being made about what the right actions might be. Like many ethical dilemmas which arise in medicine and healthcare, it depends on how you look the issues, and it’s important to draw on the work of sociologists and psychologists, as well as clinicians and lawyers, in order to determine what’s going on here.

Sources:

Bavington, L. 2008 Female Bodybuilders and the Feminine Mystique: Where Bev Francis meets Betty Friedan. Accessed 27-12-2009.

Ferguson, S Deformities and Diseased: the medicalization of women’s breasts in Breast cancer: society shapes an epidemic  By Anne S. Kasper, Susan J. Ferguson 2000 Palgrave New York