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To perform a systematic review to identify articles that discuss ethical issues relating to the field of plastic and reconstructive surgery and to evaluate whether ethical issues are underrepresented in the plastic surgery literature.
Four medical databases were selected to search through the medical literature with specific inclusion criteria to disqualify irrelevant articles from the study. Appropriate articles were extracted, and their quality and validity were assessed by multiple investigators to maximize reproducibility. The data were then synthesized and analyzed for associations amongst the ethical principles.
Out of a total library search of >100,000 plastic surgery oriented articles, only 110 clearly focused on ethical principles. Autonomy (53%) was the most common major theme, whereas distributive justice (15%) represented the least frequently emphasized ethical principle. The proportions of each ethical principle were tested against each other for equality using Cochran's Q test; the Q test reached statistical significance (Q = 67.04, df =3, P < 0.0001), indicating that the ethical principles were not discussed equally in plastic surgery literature, which was expected because autonomy represented 53% of the manuscripts whereas distributive justice represented only 15% of manuscripts. When examining both major and minor themes, over half of the articles (61%) addressed 2 or more ethical principles. Beneficence and nonmaleficence were strongly associated (Pearson's x2 = 55.38, df =1, P<0.0001).
Despite the extensive amount of ethical issues that plastic surgeons face, a relatively small proportion of plastic surgery literature was dedicated to discussing ethical principles.
Plastic and reconstructive surgery is continuously at the forefront of medical research and discovery. In 1954, plastic surgeon Joseph Murray led a team of surgeons to transplant a kidney into a 23-year old dying man, resulting in the first successful long-term organ transplant in a human.(1) In 1999, the plastic surgery team at Louisville helped perform the first hand transplant that achieved prolonged tissue survival, and in December 2008, plastic surgeons in Cleveland led a team in performing the first facial allotransplant in the United States. As evidenced by these examples as well as many others, plastic surgeons often guide the way in innovative surgical discoveries. However, with these novel techniques come numerous ethical challenges unique to the plastic surgery community. For example, plastic surgeons are faced with ethical dilemmas about whether to perform operations on patients to enhance what is normal rather than restoring health to the diseased or disfigured. Other ethical issues relate to conducting research using human subjects to test the effectiveness of an innovative surgical procedure, or performing surgery on a patient who may not be fully informed because of misleading advertisements and media messages.(2) Despite the complex ethical dilemmas plastic surgeons face, it is uncertain if ethical principles are adequately presented in the plastic surgery literature. Studies have shown that there is a disproportionately small amount of ethical content in the medical literature (3, 4). For example, a recent analysis of ethical content in the rheumatologic literature found that in an estimated library of >400,000 rheumatology- related articles, only 104 had an ethical focus (5).
In the United States the most widely adopted construct is principlism, or the study of ethics based on the four moral principles of autonomy, beneficence, nonmaleficence, and distributive justice (Table 1). This framework described by Beauchamp and Childress in 1979(6) represents the commonly adopted and taught foundation in medical ethics. The first of these principles – autonomy – is the respect for the patient's right to self-governance, choice in care, and the right to accept or refuse treatment. The second principle – beneficence – is the obligation to prevent or remove harm while also promoting good by contributing to the welfare and acting in the best interest of the patient. The third principle – nonmaleficence – is the obligation of physicians not to inflict harm or adverse effects on the patient from inappropriate or absent care. The fourth and final ethical principle – distributive justice – means distributing benefits, risks, and costs fairly, equitably, and appropriately, and treating patients with similar cases in a similar manner.
Because plastic surgery is continuously confronted with novel and complex ethical issues, ethical consideration should be amply presented in the plastic surgery literature. In order to examine the prevalence of ethical discussion in plastic surgery literature and to evaluate the emphasis on ethical principles, we performed a systematic review to identify all the plastic surgery publications, focusing on bioethics by relying on the framework developed by Beauchamp and Childress. We conducted this research with the hypothesis that ethical issues are underrepresented in the plastic surgery literature.
We conducted a literature search beginning in July 2008 using Medline, Cochrane Central Register for Clinically Controlled Trials, The National Reference Center for Bioethical Literature (NRCBL) and ISI Web of Science in order to identify all citations relating to plastic and reconstructive surgery and ethics (Table 2). Four medical databases were selected because prior studies emphasized the need to search a range of databases in order to identify as many relevant articles as possible (7-9).
For Medline and Cochrane Register, the following medical subject headings (MeSH) were used along with the Boolean search function, “(exp Plastic Surgery/ or exp Reconstructive Surgical Procedures/ or reconstructive surgical techniques mp/ ) and (exp ethics, nursing/ or exp ethics/ or exp ethics, clinical/ or exp ethics, medical/ or exp ethics, research/ or exp principle-based ethics/ or exp bioethics/ or exp patient rights/ or exp bioethical issues/ or exp patient advocacy/es [ethics]/ or “conflict of interest”/ or exp beneficence/ or nonmaleficence mp/ or exp personal autonomy/ or exp social justice/ or exp “delivery of health care”/es [ethics]). The ISI Web of Science interface used similar Boolean expression of keywords as Medline. Because NRCBL is an ethics database and contains only materials concerned with issues in biomedical and professional ethics, only keywords pertaining to plastic surgery were searched using Boolean expression. A complete list of keywords and MeSH headings for ISI Web of Science and NRCBL are available upon request.
We included both research and non-research manuscripts from peer-reviewed journals. Research manuscripts were categorized into either quantitative analyses or qualitative research studies. Letters to the editor, editorials/commentaries, case reports, and highlighted news stories within a scientific journal were the acceptable non-research manuscripts. Only human-based topics and articles written in English were used. The contents of these articles also had to focus on at least one of the four ethical principles of autonomy, beneficence, nonmaleficence and distributed justice, as described by Beauchamp and Childress (6).
The data were abstracted from the included articles by investigators (AP, LB) and verified by the senior author (KCC) who has substantial expertise in systematic reviews and meta-analyses (8, 10-14). We collected data for each of the 4 ethical principles and reported major and minor themes separately (Figure 1).
After identifying the articles that met our specific criteria, the manuscripts were classified by which of the four of Beauchamp and Childress' ethical principles were described. The major and minor themes were reported separately. After categorizing the data, we used the Cochran Q test to assess whether all four of the ethical principles were discussed equally in the plastic surgery literature.(15)
A Pearson chi-square test was performed between each pair of principles discussed as either a major or a minor theme to determine if any of the 4 principles tended to appear together. If a chi-square test was found to be significant, the phi coefficient for nominal variables was used to determine strength and direction of the association.(15) Positive associations were reported. Using the cutoffs suggested by Cohen, a phi-coefficient value > 0.30 was taken to indicate moderate positive association, 0.10-0.29 to indicate a small positive association, and any value <0.10 to indicate no positive association (16).
From our extensive search, 638 articles were identified. A trial flow diagram was followed and articles were excluded for several reasons, either they focused on issues other than plastic and reconstructive surgery (233), did not have sufficient bioethical discourse (196), were non peer-reviewed or non-English sources (39), or were duplicates (60) (Figure 2).
The total number of articles focusing on ethical principles was 110 out of an estimated >100,000 plastic and reconstructive surgery oriented published manuscripts (~ .1%) (See Appendix 1). Of the total 110 manuscripts, 36% represented original research ((28%) qualitative and (8%) quantitative research), whereas 64% were non-research in nature. Fifty-one percent of the total manuscripts were editorial/commentary articles, 5% were case reports, and 8% were letters to the editor (Table 3).
The included articles addressed a broad spectrum of ethical concepts, broaching at least one of the ethical principles. The articles were read and categorized by the ethical principle(s) that was focused on in the paper (major theme). The majority of the articles also discussed additional bioethical principles that were clearly not the main focus (having only a couple sentence discourse) and this discourse was also noted (minor themes) (see figure 1). From the major themes, respect for autonomy was the most common, representing 53% of the manuscripts. Beneficence (21%) and nonmaleficence (19%) were discussed in approximately equal number of papers. Distributive justice (15%) was the least discussed. Testing using the Cochran's Q statistic confirmed that the percent representation of the principles were significantly different (Q =38.79, df =3, P<0.0001). Because 7 articles had more than one major theme, each principle was counted separately and the numbers were divided by the total number of articles (110). Therefore, these percentages do not add up to 100% (see Table 3).
Approximately 55% of the articles discussed more than 1 ethical principle (Figure 3). The majority of these articles tended to focus on one ethical principle and only briefly touch upon the others. In order to determine if any of the ethical principles tended to appear in the same article, a Pearson's chi-square analysis between each of the possible pairs was conducted. Of the 6 possible pairs, one pair-- beneficence and nonmaleficence -- was found to have a statistically significant tendency to appear together (Pearson's x2 = 55.38, df =1, P <0.0001). The phi coefficient was 0.71, indicating a moderately strong positive association.
When considering both major and minor ideas, autonomy was still the most common, with 78% of the articles having either major (58 articles) or minor (28 articles) reflection on this subject. Similar to the previous findings that only took major themes into account, distributive justice appeared most infrequently (25%) when considering both major and minor ideas. Beneficence and nonmaleficence were approximately equal with each occurring in approximately 50% and 48% of all articles, respectively.
Finally, after reviewing all 110 articles, we found that there were 3 broad topics that often featured bioethical discussion in plastic surgical literature. These categories included patient informed consent (32%), facial allotransplant (19%), and resource rationing and managed care (7%).
Bioethics is a relatively young field, only beginning to develop institutionally and professionally during the late 1960s and 1970s. Nevertheless, this field has grown exponentially over these past decades and will continue to develop in conjunction with the advancement of medicine, science, and biotechnology (17).
Despite the meticulous and extensive search, we found plastic and reconstructive surgical literature contained only a relatively small number of manuscripts focusing on ethical issues. Given the prominence of bioethics in modern medicine and the unique and challenging quandaries associated with plastic surgery, we would expect a higher number of manuscripts devoted to ethics. Instead, we found a substantial gap in the amount of ethical inquiry in plastic and reconstructive surgical literature. These findings are consistent with Frederick A. Paola's prior review on this subject, reporting that an “ethics gap” exists between medical and the surgical subspecialty, with medical literature having a much greater percentage of literature devoted to bioethics (3, 4). The reason for this scarcity of bioethical publications is unclear, but may reflect different priorities within plastic surgery, a lack of understanding of formal ethical concepts, a detached research interest in bioethics, discomfort with non-quantitative disciplines, or a variety of other reasons (5). Nonetheless, it is concerning that plastic surgery literature is substantially lacking in ethical discourse.
The retrieved manuscripts included sources addressing all 4 of Beauchamp and Childress' ethical principles (Table 1); however, the frequency of each principle varied. Autonomy was by far the most common theme, which is somewhat expected with issues ranging from informed consent (18-20), photography (21) and advertising (22-24), are all which are particularly pertinent to plastic surgery. Makdessian et al.(19) illustrated the importance of autonomy in facial plastic surgery by conducting a study designed to examine informed consent and the effectiveness of oral communication versus written communication about the risks of facial cosmetic procedures. They found that those patients who received oral and written communication about the risks involved with cosmetic procedures had a significantly better recall rate than those who had just oral communication about the risks. These findings are important for a field in which litigation rates can be particularly high if a patient does not fully understand the risk associated with cosmetic surgery procedures (25-27).
Exactly half of the articles found in this review discussed beneficence to some extent. Discussion of beneficence generally focuses around assessing risks versus benefits and judging whether the potential benefits outweigh the potential risks (28). For example, in an article on facial transplantation, Barker et al.(1) quantitatively assessed risk acceptance in facial transplantation by examining the question, “Do the risks posed by long term immunosuppression that the recipient would have justify the benefits of receiving a face transplant?” The authors proposed the Louisville Instrument for Transplantation, LIFT, which asked respondents about how many specific number of life years or other costs they would trade off in exchange for receiving 7 different transplant procedures: foot, hand, larynx, kidney, two hands, hemiface, and face. Even after the respondents were fully informed of the potential risks of rejection and long-tem immunosuppression, a significant majority of the subjects said they would undergo the facial transplantation procedure. This study provides evidence in supporting the view that it may be appropriate for patients with facial disfigurations to be invited to participate in clinical studies associated with transplantation surgery (1).
Nonmaleficence is an ethical principle that is often associated with beneficence (P<0.0001). They are related principles; however, nonmaleficence can be distinguished from beneficence because it focused only on the physician's obligation not to inflict harm on a patient and does not imply an act toward the greater good nor does it take benefit into account. This review found that nonmaleficence occurred in slightly less than half of the plastic surgery oriented manuscripts. One of the articles discussing nonmaleficence was written by Miller et al. (29) and evaluated how nonmaleficence relates to plastic surgery, particularly the cosmetic surgery component of plastic surgery. This manuscript stated, “Although increasingly popular, cosmetic surgery is a most unusual medical practice. Invasive surgical operations performed on healthy bodies for the sake of improving appearance lie far outside the core domain of medicine as a profession dedicated to saving lives, healing, and promoting health. These cosmetic procedures are not medically indicated for a diagnosable medical condition. Yet they pose risks, cause side effects, and are subject to complications…”(29) The authors examined the inconsistencies between cosmetic surgery and the basic tenet of nonmaleficence, “primum non nocere” (first do no harm). Reflecting on both principles of nonmaleficence and autonomy, Miller et al. argued that cosmetic surgery may be considered as a peripheral medical practice, somewhat similar to sterilization or contraceptives. The authors further argued that in order to keep cosmetic surgery inside the bounds of allowable medical activity, additional steps needed to be taken to curb the unethical marketing of cosmetic surgery procedures (29).
The last of Beauchamp and Childress' ethical principles, distributive justice, refers to society's responsibility to distribute benefits, risks, and costs fairly and appropriately. The topic of distributive justice has become increasingly relevant to the practice of medicine, as debates about universal healthcare increase in the United States; however, this trend has not been mirrored in the plastic surgery literature, as this was the least discussed ethical principle in the plastic surgery literature. Several of the articles that discussed distributive justice focused on reconstructive procedures and managed care environments, often centering on breast reconstruction or the acceptance or denial of care to patients infected with human immunodeficiency virus (HIV). An article written by Davison et al.(30) discussed the ethical dilemmas that arise when treating HIV patients. Throughout the 1980s and 1990s, ethical issues arose about whether a plastic surgeon was obligated to treat an HIV-positive patient who was seeking cosmetic or reconstructive surgery. Many plastic surgeons argued that it was inappropriate to treat an HIV positive patient seeking elective surgery because of the potential risks of exposure and transmission of the disease from the patient to the operating team. Conversely, not treating this group of individuals could be viewed as discrimination and not ethically sound under the tenet of distributive justice. Davison et al. reports that it became clear later that the risk of transmission was only minimal, and the task force report from the American Society of Plastic and Reconstructive Surgeons declared that discrimination against HIV-positive patient was not to be endorsed.(30)
In general, our findings indicate that bioethical discourse in plastic surgical literature tends to restrict its focus on a single, major ethical principle while only briefly mention others. One exception to this is with the issue of facial allotransplant. This topic had the largest extent of ethical discussion, as the majority of the articles on this topic focused on 2 or more ethical principles relating to facial allotransplant. This is most likely due to the wide array of ethical dilemmas associated with facial allotransplant. Challenges regarding risks versus benefits of this procedure (beneficence), dangerous side-effects from continuous immunosuppression agents (nonmaleficence), and truly informed consent from both the recipient and donor's family (autonomy) were are all common arenas for discussion (31-35). The comprehensiveness of ethical discourse on such a novel topic is noteworthy and may indicate a current shift toward a broader discussion of ethical principles.
This systematic review was limited by the quality of published reports. The majority of the manuscripts that matched our inclusion criteria were non-research based, leading to inherent biases in these reports. Furthermore, in such a broad and complicated topic such as “bioethics,” definition biases of an individual reviewer may influence the results. We attempted to resolve this bias by using 2 reviewers to abstract the articles and applying only Beauchamp and Childress' principle-based approach to bioethics, which served as a classification system in order to analyze retrieved literature and help curb reviewer biases. We chose Beauchamp and Childress framework because it is the most widely adopted and taught scheme in medical ethics across healthcare disciplines in the United States (36-38). Although we selected the ethical framework most familiar to healthcare providers, we acknowledge that this may have slightly limited our methodology and that an alternative classification system would have revealed a different distribution of ethical content in the plastic surgical literature.
This review has shown that there is an extremely low frequency of ethical discourse in the plastic surgical literature, and that the 4 ethical principles of autonomy, beneficence, nonmaleficence, and distributive justice are not addressed equally. For the field of plastic surgery to continuously advance, plastic surgeons need to devote more attention to ethical reflection. This study should serve as a stimulus to help promote the growth in all areas of ethical discourse.
Supported in part by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01 AR047328) and a Midcareer Investigator Award in Patient-Oriented Research (K24 AR053120) (to Dr. Kevin C. Chung).
We appreciate the assistance of Ann Haas, MPH, in the statistical analyses portion of this review.
The final list of the 110 articles which were included in this systematic review.
|Author Name(s)||Journal||Title of Article||Major|
|Agich, G.J.; Siemionow,|
|J.Med.Ethics||Until they have faces: the ethics of facial allograft transplantation.[see|
|Altchek, E. D.||Plast Reconstr. Surg||informed consent||1|
|Armenio, A. et al.||Plast Reconstr. Surg||Informed consent and its central role in plastic and cosmetic surgery||1||3|
|Armstrong, A. P. et al.||Br. J. Plast. Surg||Informed consent: are we doing enough?||1|
|Atiyeh, B. S. et al.||Aesthetic Plast Surg||Aesthetic surgery and religion: Islamic law perspective (?)||1||2,3,4|
|Aylott, J.||Br. J. Nurs||Should Children with Down Syndrome have cosmetic surgery?||1|
|Barker, J. H. et al.||Plast Reconstr. Surg||Investigation of Risk acceptance in facial transplantation||2||3|
|Barker, J.H.et al.||Ann Plast Surg||Ethical considerations in human facial tissue allotransplantation.||2||1,3|
|Baroudi, R.||Ann Plast Surg||Why Aesthetic Plastic Surgery Became Popular in Brazil||1|
|Bartley, G. B. ; Linberg,|
|Opthalmology||Cosmetic surgery may be hazardous…for the doctor as well as the|
|Bateman, N. D.;|
Woolford, T. J.
|J. Laryngol Otol||Informed consent for septal surgery: the evidence-base||1||3|
|Black, D.A.; McCraw,|
|Plast Reconstr. Surg||Does estrogen-based therapy add to the risk of aesthetic surgery?||3||1|
|Black, J.||PSN||“Medically Necessary:” Who Should Decide?||2|
|Bland, K. I.||Plast Reconstr. Surg||Oncologic and plastic surgeons: colleagues, collaborators, and|
|Bolland, B.J. et al.||Plast Reconstr. Surg||A simple tool for outpatient counseling for breast augmentation||1|
|Bosch, X.||Lancet||Surgeon denied ethics approval for face transplantation||3||1|
|Brahams, D.||Lancet||Cosmetic surgery: Greater duty to warn of risks||1|
|Bull, T. R.||LJ. Laryngol Otol||Rhinoplasty: aesthetics, ethics, and airway||2||1|
|Cantor, J.D.||Plast Reconstr. Surg||When an adult female seeks ritual genital alteration: ethics, law, and|
the parameters of participation.
|Carey, J. S.||Aesthetic Plast Surg||Microtia: a personal case study||2||1,3|
|Castanares, S.||Aesthetic Plast Surg||Ethics in Aesthetic Surgery||3|
|Chatterjee, A.||Camb Q Health Ethics||Cosmetic Neurology and Cosmetic Surgery: Parallels, Predictions,|
|Clark, P.A.||Med. Sci. Monit||Face Transplantation: a medical perspective||3||2|
|Clarke, A.; Butler, P. E.|
|Expert Opin Biol Ther||Facial transplantation: adding to the reconstructive options after|
severe facial injury and disease
|Cole, N. M||Clin. Plast. Surg||Informed consent: considerations in aesthetic and reconstructive|
surgery of the breast
|Cole, N. M.||Clin Plast Surg||informed consent - considerations in aesthetic and reconstructive|
surgery of the breast
|Daaboul, J. ; Frader, J.||J. Pediatr. Endocrinol. Metab||Ethics and the management of the patient with intersex: a middle way||1||2|
|Danino, A. M. et al.||Plast Reconstr. Surg||Visual documentation of oral consent: a new method of informed|
consent before major gigantomastia reduction for an illiterate
|Davison, S. P. et al.||Plast Reconstr. Surg||Preoperative guidelines for elective surgery in the human|
immunodeficiency virus-positive patient
|de Chalain, T. M. B.||Plast Reconstr. Surg||Ethical Resource Allocation and the Quest for Normalcy: Is Pediatric|
Reconstructive Surgery Justified?
|Evans, M.||Aust. J. Adv. Nurs||Augmentation mammaplasty: neither simple nor safe||1|
|Frankel, C. A.; Juengst,|
|J. Pediatr. Ophthalmol.|
|Cosmetic Surgery for a Fatally Ill Infant||1||2|
|Frankel, J.||Surv. Ophthalmol||Maloccurrence in oculoplastic surgery related to the managed care|
|Friedland, B.||Plast Reconstr. Surg||The Americans with Disabilities Act: Should it Compel Cosmetic|
Treatment for HIV Positive Individuals?
|Glasper, E. Powell, C.||Br. J. Nurs||Facial surgery and children with Down's syndrome||1||2,3|
|Goering, S.||Am. J. Bioeth||Facing the consequences of facial transplantation: individual choices,|
|Golan, J. Ben-Hur. N.||Med Law||informed consent in plastic surgery||1|
|Goldwyn, R. M.||J. Am Podiatr. Med. Assoc||Reality in plastic surgery. A plea for complete disclosure of results||1|
|Goldwyn, R. M.||Plast Reconstr. Surg||Unproven treatment: whose benefit, whose responsibility?||3|
|Goldwyn, R. M.||Plast Reconstr. Surg||AIDS, Aesthetic Surgery, and the Plastic Surgeon||4|
|Greenberg, G.||Clin. Plast. Surg||Lipoplasty: the informed consent and medicolegal considerations||1|
|Greene, J.||Hosp Health Netw||Al wants more hair, less fat and a better sex life…and he wants his|
health plan to pay for it.
|Habal, M.B.||J. Craniofac Surg||Issues concerning crossing the barriers in plastic surgery||2,3|
|Hale, C. J.||Perspect.Biol.Med||Ethical problems with the mental health evaluation standards of care|
for adult gender variant prospective patients
|Hamdy, R. C.||South Med J||Face transplantation: a brave or maverick surgery?.||2||1,3|
|Hendi, J.M. et al.||J. Craniofac Surg||Plastic surgery considerations for holoprosencephaly patients.||2||3|
|Hermer, L.||Ann Health Law||Paradigms revised: intersex children, bioethics & the law||1|
|Hilhorst, M. T.||Med Hum||Philosophical pitfalls in cosmetic surgery: a case of rhinoplasty during|
|Holden, C.||Science||Face transplants: next step in plastic surgery?||2||1,3|
|Horner, B.||Ann R. Coll Surg Engl||Breast augmentation should be on the NHS: a discussion of the ethics|
|Horton, J.B et al.||Plast Reconstr. Surg||Patient safety in the office-based setting||3||1,2|
|Huxtable, R.; Woodley,|
|J. Med Ethics||(When) will they have faces? A response to Agich and|
|Huxtable, R.; Woodley,|
|Bioethics||Gaining face or losing face? Framing the debate on face transplants.||1,2,3|
|Hyman, D. A.||Perspect.Biol.Med||Aesthetics and ethics: the implications of cosmetic surgery.||3||1,2,4|
|Jacobs, E. W.||Plast Reconstr. Surg||Another dimension for informed consent||1|
|Jonsen, A. R.||Plast Reconstr. Surg||The fall of Asklepios: medicine, mortality, and money||4|
|Kalter, P.O et al.||Facial Plast Surg||Medicolegal aspects of otolaryngolic, facial plastic, and reconstructive|
|Kay, J. B. et al||Plast Reconstr. Surg||Social response in children with severe cognitive impairments: Factors|
in craniofacial surgery decision-making
|Kessler, D. A. et al||JAMA||A call for higher standards for breast implants||1|
|Laskin, D. M.||J. Oral Maxillofac. Surg.||Do you get the picture||1|
|Levine, J.M. et al.||Arch Facial Plast Surg||Informed consent for rhytidectomy: a survey of AARPRS fellowship|
|Lister, G. D.||Plast Reconstr. Surg||Ethics in Surgical Practice||1||2|
|Makdessian, A.S. et al||Arch Facial Plast Surg||Informed consent in facial plastic surgery: effectiveness of a simple|
|Mantese, T. et al.||Mich Bar J||Cosmetic Surgery and Informed Consent||1|
|McCoy, J. P.||Ethics Sci Med||Plastic Surgery and the limits of medicine||2,3|
|McG Taylor, D et al.||J. Plast. Reconstr. Aesthet. Surg.||A study of the personal use of digital photography within plastic|
|Meningaud, J.P. et al.||Med. Law||Ethics and aims of cosmetic surgery: a contribution from an analysis|
of claims after minor damage
|Miller, F. G. et al.||Camb Q Health Ethics||Cosmetic Surgery and the Internal Morality of medicine||3||1,2|
|Morain, W. D.||Plast Reconstr. Surg||Reply to the editorial on AIDS, aesthetic surgery, and the plastic|
|Morain, W. D.||Ann Plast Surg||Hollow Fears||4|
|Morris, P. et al.||Transplantation||Face Transplantation: A Review of the Technical, Immunological,|
Psychological and Clinical Issues with Recommendations for Good
|Mouradian, W. E.||CPCJ||Who decides? Patients, Parents, or Gatekeepers: Pediatric Decisions|
in the Craniofacial Setting
|Nardi, C.||Wisconsin Law Review||WHEN HEALTH INSURERS DENY COVERAGE FOR BREAST|
RECONSTRUCTIVE SURGERY: GENDER MEETS DISABILITY
|O'Brien, C. M. et al.||J Plast Reconstr Aesthet Surg||Consent for plastic surgical procedures.||1||2,3|
|Olbourne, N. A.||J Law and Med||The influence of Rogers v. Whitaker on the practice of cosmetic|
|Padgett, B. L.; Haas, T.||Plast Surg Nurs||An ethical wrinkle of the face of therapy claims||1|
|Peled, Z.M.; Pribaz, J.|
|South Med J||Face transplantation: the view from Harvard Medical School.||1||2,3|
|Petit, F. et al.||Plast Reconstr. Surg||Face Transplantation: Where do we stand?||3||2|
|Pleat, J. M. et al.||Plast Reconstr. Surg||Communication of risk in breast augmentation||1|
|Pomahac, B. et al||Transplantation||Facial transplantation and immunosuppressed patients: A new frontier|
in reconstructive surgery
|Rangecroft, L.||Arch Dis Child||Surgical management of ambiguous genitalia||2||1,3|
|Redden, E. M. et al.||Plast Reconstr. Surg||The Patient, the Plastic Surgeon, and Informed Consent: New Insights|
into Old Problems
|Reddick, L. P.||Plast Reconstr. Surg||From a Broken Soapbox: Misadventures in Plastic Surgery||1||2,3,4|
|Rohrich, R. J.||Plast Reconstr. Surg||Ethical approval of clinical studies, informed consent, and the|
Declaration of Helsinki: what you need to know.
|Rudd, L.J.||Clin. Plast. Surg||Legal Issues in pediatric plastic surgery||1|
|Ruel, M. D.||J. Leg Med||Vanity Tax||4|
|Sheldon, S. Wilkinson,|
|Bioethics||Female genital mutilation and cosmetic surgery: regulating non|
therapeutic body modification
|Siemionow, M. et al.||Curr. Opin. Organ Transpl||Ethical issues in face transplantation||1||2,3|
|Clin Plast Surg||Tissue transplantation in plastic surgery||2,3||1|
|Sorta-Bilajac, I.; Juretic,|
M.; Muzur, A.
|Otolaryn Health. Neck Surg||Bioethics of appearance and the quality of life issue: who makes the|
|Spilson, S. V. et al.||Plast Reconstr. Surg||Are plastic surgery advertisements conforming to the ethical codes of|
the American society of plastic surgeons?.
|Sullivan, P.||CMAJ||Plastic surgeons take advantage of relaxed rules, launch ad|
|Suziedelis, A. K.||Health Care Ethics USA||Cosmetic surgery for children with Down Syndrome: the cruelest cut|
|Szajerka, T. et al.||Adv. Clin Exp Med||Face transplantation - New possibilities and risks||3||1,2|
|Taure, H. et al.||J. Oral Maxillofac. Surg.||Facial Transplantation: A Comprehensive Review of the Literature||3||2|
|Tebbetts, J. B.; Tebbetts, T. B.||Plast Reconstr. Surg||An approach that integrates patient education and informed consent in|
|Tempest, M. N.||Br. J. Plast. Surg||Is the policy of informed consent in the interest of the surgeons of the|
|Tracy, E. E.||Obstet.Gynecol||Elective vulvoplasty: a bandage that might hurt.||3||1|
|Ward, C. M.||Br. J. Plast. Surg||Consenting and Consulting for cosmetic surgery||1|
|Ward, C. M.||Br. J. Plast. Surg||Advertising and boundary disputes||1|
|Ward, C. M.||Br. J. Plast. Surg||Rationing and resource management||4|
|Ward, C. M.||Br. J. Plast. Surg||Surgical Research, experimentation, and innovation||1||2,3|
|Ward, C. M.||Br. J. Plast. Surg||Consenting to Surgery||1|
|Ward, C. M.||Br. J. Plast. Surg||Defining medical ethics||1||2,3,4|
|Ward, C. M.||Br. J. Plast. Surg||An ethical and legal perspective on foetal surgery||2||1,3|
|Webb, S. M.||Ann Plast Surg||Medical ethics under managed care: how can the patient survive?||4||1,2,3|
|Wiggins, O.P. et al.||Am. J. Bioeth||On the ethics of facial transplantation research||2,3||1|
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