PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Plast Reconstr Surg. Author manuscript; available in PMC 2010 November 1.
Published in final edited form as:
PMCID: PMC2796557
NIHMSID: NIHMS149428

A Systematic Review of Ethical Principles in the Plastic Surgery Literature

Abstract

Background:

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.

Methods:

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.

Results:

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).

Conclusions:

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.

Keywords: Systematic Review, Ethics, Principles, Plastic Surgery

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.

Table 1
Descriptions of Beauchamp and Childress' four ethical principles and how each pertains to plastic surgery.

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.

Materials and Methods

Search Criteria

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).

Table 2
Specific databases and search interfaces used.

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.

Inclusion criteria

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).

Identification, selection and classification of relevant manuscripts

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).

Figure 1
Distribution of ethical principles. Autonomy is the most commonly discussed with 58 articles having autonomy as a major theme and 28 articles discussing autonomy in brevity.

Statistical Analysis

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).

Results

Study Retrieval

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).

Figure 2
Flow chart showing search strategy, inclusion and exclusion criteria, and citation results.

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).

Table 3
The number and proportion of manuscripts addressing each ethical principle.

Article Characteristics

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.

Figure 3
The number of ethical principles covered in each article.

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%).

Discussion

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.

Acknowledgements

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.

Appendix 1

The final list of the 110 articles which were included in this systematic review.

Author Name(s)JournalTitle of ArticleMajor
Theme(s)
Minor
Theme(s)
Agich, G.J.; Siemionow,
M.
J.Med.EthicsUntil they have faces: the ethics of facial allograft transplantation.[see
comment]
23
Altchek, E. D.Plast Reconstr. Surginformed consent1
Armenio, A. et al.Plast Reconstr. SurgInformed consent and its central role in plastic and cosmetic surgery13
Armstrong, A. P. et al.Br. J. Plast. SurgInformed consent: are we doing enough?1
Atiyeh, B. S. et al.Aesthetic Plast SurgAesthetic surgery and religion: Islamic law perspective (?)12,3,4
Aylott, J.Br. J. NursShould Children with Down Syndrome have cosmetic surgery?1
Barker, J. H. et al.Plast Reconstr. SurgInvestigation of Risk acceptance in facial transplantation23
Barker, J.H.et al.Ann Plast SurgEthical considerations in human facial tissue allotransplantation.21,3
Baroudi, R.Ann Plast SurgWhy Aesthetic Plastic Surgery Became Popular in Brazil1
Bartley, G. B. ; Linberg,
J. V.
OpthalmologyCosmetic surgery may be hazardous…for the doctor as well as the
patient
21,3
Bateman, N. D.;
Woolford, T. J.
J. Laryngol OtolInformed consent for septal surgery: the evidence-base13
Black, D.A.; McCraw,
J.B.
Plast Reconstr. SurgDoes estrogen-based therapy add to the risk of aesthetic surgery?31
Black, J.PSN“Medically Necessary:” Who Should Decide?2
Bland, K. I.Plast Reconstr. SurgOncologic and plastic surgeons: colleagues, collaborators, and
teammates
41
Bolland, B.J. et al.Plast Reconstr. SurgA simple tool for outpatient counseling for breast augmentation1
Bosch, X.LancetSurgeon denied ethics approval for face transplantation31
Brahams, D.LancetCosmetic surgery: Greater duty to warn of risks1
Bull, T. R.LJ. Laryngol OtolRhinoplasty: aesthetics, ethics, and airway21
Cantor, J.D.Plast Reconstr. SurgWhen an adult female seeks ritual genital alteration: ethics, law, and
the parameters of participation.
12,3,4
Carey, J. S.Aesthetic Plast SurgMicrotia: a personal case study21,3
Castanares, S.Aesthetic Plast SurgEthics in Aesthetic Surgery3
Chatterjee, A.Camb Q Health EthicsCosmetic Neurology and Cosmetic Surgery: Parallels, Predictions,
and Challenges
41,2,3
Clark, P.A.Med. Sci. MonitFace Transplantation: a medical perspective32
Clarke, A.; Butler, P. E.
M
Expert Opin Biol TherFacial transplantation: adding to the reconstructive options after
severe facial injury and disease
21,3
Cole, N. MClin. Plast. SurgInformed consent: considerations in aesthetic and reconstructive
surgery of the breast
1
Cole, N. M.Clin Plast Surginformed consent - considerations in aesthetic and reconstructive
surgery of the breast
1
Daaboul, J. ; Frader, J.J. Pediatr. Endocrinol. MetabEthics and the management of the patient with intersex: a middle way12
Danino, A. M. et al.Plast Reconstr. SurgVisual documentation of oral consent: a new method of informed
consent before major gigantomastia reduction for an illiterate
population.
12
Davison, S. P. et al.Plast Reconstr. SurgPreoperative guidelines for elective surgery in the human
immunodeficiency virus-positive patient
3,41,2
de Chalain, T. M. B.Plast Reconstr. SurgEthical Resource Allocation and the Quest for Normalcy: Is Pediatric
Reconstructive Surgery Justified?
41
Evans, M.Aust. J. Adv. NursAugmentation mammaplasty: neither simple nor safe1
Frankel, C. A.; Juengst,
E. T.
J. Pediatr. Ophthalmol.
Strabismus
Cosmetic Surgery for a Fatally Ill Infant12
Frankel, J.Surv. OphthalmolMaloccurrence in oculoplastic surgery related to the managed care
environment.
4
Friedland, B.Plast Reconstr. SurgThe Americans with Disabilities Act: Should it Compel Cosmetic
Treatment for HIV Positive Individuals?
4
Glasper, E. Powell, C.Br. J. NursFacial surgery and children with Down's syndrome12,3
Goering, S.Am. J. BioethFacing the consequences of facial transplantation: individual choices,
social effects
12,3
Golan, J. Ben-Hur. N.Med Lawinformed consent in plastic surgery1
Goldwyn, R. M.J. Am Podiatr. Med. AssocReality in plastic surgery. A plea for complete disclosure of results1
Goldwyn, R. M.Plast Reconstr. SurgUnproven treatment: whose benefit, whose responsibility?3
Goldwyn, R. M.Plast Reconstr. SurgAIDS, Aesthetic Surgery, and the Plastic Surgeon4
Greenberg, G.Clin. Plast. SurgLipoplasty: the informed consent and medicolegal considerations1
Greene, J.Hosp Health NetwAl wants more hair, less fat and a better sex life…and he wants his
health plan to pay for it.
4
Habal, M.B.J. Craniofac SurgIssues concerning crossing the barriers in plastic surgery2,3
Hale, C. J.Perspect.Biol.MedEthical problems with the mental health evaluation standards of care
for adult gender variant prospective patients
1*,2,34
Hamdy, R. C.South Med JFace transplantation: a brave or maverick surgery?.21,3
Hendi, J.M. et al.J. Craniofac SurgPlastic surgery considerations for holoprosencephaly patients.23
Hermer, L.Ann Health LawParadigms revised: intersex children, bioethics & the law1
Hilhorst, M. T.Med HumPhilosophical pitfalls in cosmetic surgery: a case of rhinoplasty during
adolescence
12
Holden, C.ScienceFace transplants: next step in plastic surgery?21,3
Horner, B.Ann R. Coll Surg EnglBreast augmentation should be on the NHS: a discussion of the ethics
of rationing
4
Horton, J.B et al.Plast Reconstr. SurgPatient safety in the office-based setting31,2
Huxtable, R.; Woodley,
J.
J. Med Ethics(When) will they have faces? A response to Agich and
Siemionov.[comment]
21,3,4
Huxtable, R.; Woodley,
J.
BioethicsGaining face or losing face? Framing the debate on face transplants.1,2,3
Hyman, D. A.Perspect.Biol.MedAesthetics and ethics: the implications of cosmetic surgery.31,2,4
Jacobs, E. W.Plast Reconstr. SurgAnother dimension for informed consent1
Jonsen, A. R.Plast Reconstr. SurgThe fall of Asklepios: medicine, mortality, and money4
Kalter, P.O et al.Facial Plast SurgMedicolegal aspects of otolaryngolic, facial plastic, and reconstructive
surgery
1
Kay, J. B. et alPlast Reconstr. SurgSocial response in children with severe cognitive impairments: Factors
in craniofacial surgery decision-making
12,3,4
Kessler, D. A. et alJAMAA call for higher standards for breast implants1
Laskin, D. M.J. Oral Maxillofac. Surg.Do you get the picture1
Levine, J.M. et al.Arch Facial Plast SurgInformed consent for rhytidectomy: a survey of AARPRS fellowship
programs
1
Lister, G. D.Plast Reconstr. SurgEthics in Surgical Practice12
Makdessian, A.S. et alArch Facial Plast SurgInformed consent in facial plastic surgery: effectiveness of a simple
educational intervention
1
Mantese, T. et al.Mich Bar JCosmetic Surgery and Informed Consent1
McCoy, J. P.Ethics Sci MedPlastic Surgery and the limits of medicine2,3
McG Taylor, D et al.J. Plast. Reconstr. Aesthet. Surg.A study of the personal use of digital photography within plastic
surgery
1
Meningaud, J.P. et al.Med. LawEthics and aims of cosmetic surgery: a contribution from an analysis
of claims after minor damage
2
Miller, F. G. et al.Camb Q Health EthicsCosmetic Surgery and the Internal Morality of medicine31,2
Morain, W. D.Plast Reconstr. SurgReply to the editorial on AIDS, aesthetic surgery, and the plastic
surgeon
4
Morain, W. D.Ann Plast SurgHollow Fears4
Morris, P. et al.TransplantationFace Transplantation: A Review of the Technical, Immunological,
Psychological and Clinical Issues with Recommendations for Good
Practice
31,2
Mouradian, W. E.CPCJWho decides? Patients, Parents, or Gatekeepers: Pediatric Decisions
in the Craniofacial Setting
12,3,4
Nardi, C.Wisconsin Law ReviewWHEN HEALTH INSURERS DENY COVERAGE FOR BREAST
RECONSTRUCTIVE SURGERY: GENDER MEETS DISABILITY
41
O'Brien, C. M. et al.J Plast Reconstr Aesthet SurgConsent for plastic surgical procedures.12,3
Olbourne, N. A.J Law and MedThe influence of Rogers v. Whitaker on the practice of cosmetic
plastic surgery
1
Padgett, B. L.; Haas, T.Plast Surg NursAn ethical wrinkle of the face of therapy claims1
Peled, Z.M.; Pribaz, J.
J.
South Med JFace transplantation: the view from Harvard Medical School.12,3
Petit, F. et al.Plast Reconstr. SurgFace Transplantation: Where do we stand?32
Pleat, J. M. et al.Plast Reconstr. SurgCommunication of risk in breast augmentation1
Pomahac, B. et alTransplantationFacial transplantation and immunosuppressed patients: A new frontier
in reconstructive surgery
21,3
Rangecroft, L.Arch Dis ChildSurgical management of ambiguous genitalia21,3
Redden, E. M. et al.Plast Reconstr. SurgThe Patient, the Plastic Surgeon, and Informed Consent: New Insights
into Old Problems
1
Reddick, L. P.Plast Reconstr. SurgFrom a Broken Soapbox: Misadventures in Plastic Surgery12,3,4
Rohrich, R. J.Plast Reconstr. SurgEthical approval of clinical studies, informed consent, and the
Declaration of Helsinki: what you need to know.
12
Rudd, L.J.Clin. Plast. SurgLegal Issues in pediatric plastic surgery1
Ruel, M. D.J. Leg MedVanity Tax4
Sheldon, S. Wilkinson,
S.
BioethicsFemale genital mutilation and cosmetic surgery: regulating non
therapeutic body modification
31,3
Siemionow, M. et al.Curr. Opin. Organ TransplEthical issues in face transplantation12,3
Siemionow, M.;
Agaoglu, G.
Clin Plast SurgTissue transplantation in plastic surgery2,31
Sorta-Bilajac, I.; Juretic,
M.; Muzur, A.
Otolaryn Health. Neck SurgBioethics of appearance and the quality of life issue: who makes the
decision?[comment].
12,3
Spilson, S. V. et al.Plast Reconstr. SurgAre plastic surgery advertisements conforming to the ethical codes of
the American society of plastic surgeons?.
1
Sullivan, P.CMAJPlastic surgeons take advantage of relaxed rules, launch ad
campaigns
1
Suziedelis, A. K.Health Care Ethics USACosmetic surgery for children with Down Syndrome: the cruelest cut
of all?
2
Szajerka, T. et al.Adv. Clin Exp MedFace transplantation - New possibilities and risks31,2
Taure, H. et al.J. Oral Maxillofac. Surg.Facial Transplantation: A Comprehensive Review of the Literature32
Tebbetts, J. B.; Tebbetts, T. B.Plast Reconstr. SurgAn approach that integrates patient education and informed consent in
breast augmentation
1
Tempest, M. N.Br. J. Plast. SurgIs the policy of informed consent in the interest of the surgeons of the
patients?
1
Tracy, E. E.Obstet.GynecolElective vulvoplasty: a bandage that might hurt.31
Ward, C. M.Br. J. Plast. SurgConsenting and Consulting for cosmetic surgery1
Ward, C. M.Br. J. Plast. SurgAdvertising and boundary disputes1
Ward, C. M.Br. J. Plast. SurgRationing and resource management4
Ward, C. M.Br. J. Plast. SurgSurgical Research, experimentation, and innovation12,3
Ward, C. M.Br. J. Plast. SurgConsenting to Surgery1
Ward, C. M.Br. J. Plast. SurgDefining medical ethics12,3,4
Ward, C. M.Br. J. Plast. SurgAn ethical and legal perspective on foetal surgery21,3
Webb, S. M.Ann Plast SurgMedical ethics under managed care: how can the patient survive?41,2,3
Wiggins, O.P. et al.Am. J. BioethOn the ethics of facial transplantation research2,31
Wijsbek, H.Ethical Theory Mor PractHow to Regulate a Practice: The Case of Cosmetic Surgery4
Wyatt, J.P.Plast. Surg. NursPreparing for breast augmentation: informed consent.1
Plast Reconstr. SurgInformed consent for body contouring procedures in the massive weight loss patient.12,3,4

Key

1=Autonomy

2=Beneficence

3=Nonmaleficence

4=Distributive Justice

References

1. Barker JH, Furr A, Cunningham M, et al. Investigation of risk acceptance in facial transplantation. Plast Reconstr Surg. 2006;118:663–670. [PubMed]
2. Laneader AM, Wolpe PR. Ethical Considerations in Cosmetic Surgery. In: Sarwer DP, Pruzinsky T, Cash TF, et al., editors. Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery: Clinical, Empirical, and Ethical Perspectives. Lippincott Williams & Wilkins; Philadelphia: 2006. pp. 301–314.
3. Paola F, Barten SS. An 'ethics gap' in writing about bioethics: a quantitative comparison of the medical and the surgical literature. J Med Ethics. 1995;21:84–88. [PMC free article] [PubMed]
4. Paola FA, Malik TK. Bioethics in the medical subspecialty literature. Ann Ital Med Int. 1997;12:238–241. [PubMed]
5. Caplan L, Hoffecker L, Prochazka AV. Ethics in the rheumatology literature: a systematic review. Arthritis Rheum. 2008;59:816–821. [PubMed]
6. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 3 Ed. Oxford University; Oxford: 1989.
7. Dickersin K, Scherer R, Lefebvre C. Identifying relevant studies for systematic reviews. BMJ. 1994;309:1286–1291. [PMC free article] [PubMed]
8. Margaliot Z, Chung KC. Systematic reviews: a primer for plastic surgery research. Plast Reconstr Surg. 2007;120:1834–1841. [PubMed]
9. Khan KS, Kunz R, Kleijnen J, et al. Systematic Reviews to Support Evidence-Based Medicine. The Royal Society of Medicine Press; London: 2003.
10. Squitieri L, Chung KC. A systematic review of outcomes and complications of vascularized toe joint transfer, silicone arthroplasty, and PyroCarbon arthroplasty for posttraumatic joint reconstruction of the finger. Plast Reconstr Surg. 2008;121:1697–1707. [PubMed]
11. Margaliot Z, Haase SC, Kotsis SV, et al. A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg. 2005;30A:1185–1199. [PubMed]
12. Kotsis SV, Chung KC. A systematic review of the outcomes of digital sympathectomy for treatment of chronic digital ischemia. J Rheumatol. 2003;30:1788–1792. [PubMed]
13. Watt AJ, Kotsis SV, Chung KC. Risk of melanoma arising in large congenital melanocytic nevi: a systematic review. Plast Reconstr Surg. 2004;113:1968–1974. [PubMed]
14. Saddawi-Konefka D, Kim HM, Chung KC. A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia. Plast Reconstr Surg. 2008;122:1796–1805. [PubMed]
15. Everitt BS, editor. Dictionary of Statistics in the Medical Sciences. Cambridge University Press; New York, NY: 1995.
16. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd Ed. Lawrence Erlbaum Associates; Hillsdale, NJ: 1988.
17. Fox RC, Swazey JP. Examining American bioethics: its problems and prospects. Camb Q Healthc Ethics. 2005;14:361–373. [PubMed]
18. O'Brien CM, Thorburn TG, Sibbel-Linz A, et al. Consent for plastic surgical procedures. J Plast Reconstr Aesthet Surg. 2006;59:983–989. [PubMed]
19. Makdessian AS, Ellis DA, Irish JC. Informed consent in facial plastic surgery: effectiveness of a simple educational intervention. Arch Facial Plast Surg. 2004;6:26–30. [PubMed]
20. Tebbetts JB, Tebbetts TB. An approach that integrates patient education and informed consent in breast augmentation. Plast Reconstr Surg. 2002;110:971–978. discussion 979-981. [PubMed]
21. Taylor DM, Foster E, Dunkin CSJ, et al. A study of personal use of digital photography within plastic surgery. Journal of Plastic, Reconstructive, and Aesthetic Surgery. 2008;61:37–40. [PubMed]
22. Spilson SV, Chung KC, Greenfield ML, et al. Are plastic surgery advertisements conforming to the ethical codes of the american society of plastic surgeons? Plast Reconstr Surg. 2002;109:1181–1186. [PubMed]
23. Ward C. Advertising and boundary disputes. Br J Plast Surg. 1994;47:381–385. [PubMed]
24. Sullivan P. Plastic surgeons take advantage of relaxed rules, launch ad campaigns. CMAJ. 1992;146:55–57. [PMC free article] [PubMed]
25. Holt GR, Garner ET, McLarey D. Postoperative sequelae and complications of rhinoplasty. Otolaryngol Clin North Am. 1987;20:853–876. [PubMed]
26. Morrison AW. ‘Silence in court’: twenty-one years of otolaryngology litigation. J Laryngol Otol. 1990;104:162–165. [PubMed]
27. Kalter PO, van der Baan B, Vuyk H. Medicolegal aspects of otolaryngologic, facial plastic, and reconstructive surgery. Facial Plast Surg. 1995;11:105–110. [PubMed]
28. Carey JS. Microtia: a personal case study. Aesthetic Plast Surg. 1985;9:197–206. [PubMed]
29. Miller FG, Brody H, Chung KC. Cosmetic Surgery and the Internal Morality of Medicine. Camb Q Healthc Ethics. 2000;9:353–364. [PubMed]
30. Davison SP, Reisman NR, Pellegrino ED, et al. Perioperative guidelines for elective surgery in the human immunodeficiency virus-positive patient. Plast Reconstr Surg. 2008;121:1831–1840. [PubMed]
31. Habal MB. Issues concerning crossing the barriers in plastic surgery. J Craniofac Surg. 2006;17:621–622. [PubMed]
32. Barker JH, Brown CS, Cunningham M, et al. Ethical considerations in human facial tissue allotransplantation. Ann Plast Surg. 2008;60:103–109. [PubMed]
33. Goering S. Facing the consequences of facial transplantation: individual choices, social effects. Am J Bioeth. 2004;4:37–39. discussion W23-31. [PubMed]
34. Wiggins OP, Barker JH, Martinez S, et al. On the ethics of facial transplantation research. Am J Bioeth. 2004;4:1–12. [PubMed]
35. Huxtable R, Woodley J. Gaining face or losing face? Framing the debate on face transplants. Bioethics. 2005;19:505–522. [PubMed]
36. Kessel AS. Public health ethics: teaching survery and critical review. Soc Sci Med. 2003;56:1439–1445. [PubMed]
37. DuBois JM, Burkemper J. Ethics education in U.S. medical schools: a study of syllabi. Acad Med. 2002;77:432–437. [PubMed]
38. Parsons S, Barker PJ, Armstrong AE. The teaching of health care ethics to students of nursing in the UK: a pilot study. Nurs Ethics. 2001;8:45–56. [PubMed]