Cutting to the Core, edited by David Benatar, deals with ethical issues surrounding some of the most controversial surgeries in practice.  Discussed are male circumcision and female genital cutting, sex assignment and reassignment, conjoined twin separation, limb and face transplantation, cosmetic surgery, and placebo surgery.  The book is organized into six parts, each corresponding to one of these topics.  As the editor mentions in his introduction, the aim of this collection was not to present an article for each side of the subjects (i.e., one 'for' and one 'against').  Rather, the goal was to highlight the ethical issues involved with these surgeries by offering the reader various views of and approaches to these issues.  Even when the authors' conclusions agree, their approaches might not.  The chapters on cosmetic surgery, for example, involve authors who defend cosmetic surgery from those who regard it as superfluous and harmful.  But while one article displays a feminist approach, the other does not.

Benatar provides an excellent introduction, offering some background on each of the surgeries discussed and briefly summarizing each chapter.  But most notable is the section that highlights the recurring themes of the book.  Benatar took the time (and roughly five pages) to distill the content of the chapters into the issues that are most significant.  Questions concerning the limits of paternalism, the pertinence of autonomy, and the notion of normality come up time after time in this book.  Given their central importance to medical ethics, it is quite helpful to have their roles in this context underscored.

Part one begins by sorting out some of the important questions having to do with the circumcision of minors.  Some regard such procedures as mutilation.  However, this begs the question.  Mutilation is morally prohibited because it, among other things, injures and disfigures.  But circumcision only counts as mutilation if it indeed injures and disfigures.  A close look at the alleged costs and benefits of circumcision is necessary, claim the authors, for any moral assessment of the surgery.  A consideration of costs and benefits also promises to help settle another matter: the issue of informed consent.  In the case of an adult seeking surgery, the estimation of costs and benefits is done by the adult.  In the case of a minor, however, such estimation is unreliable (if not impossible).  So a clear understanding of the potential for harm and benefit may be what is required before we allow parents to decide a young boy's surgical fate.  Add to this understanding a firm grasp of the medical, ethical, social, and religious motivations behind the act of circumcising, and one puts oneself in the best position to decide for or against circumcision.

At the end of part one, attention is drawn to the various procedures collectively known as female genital alteration (FGA; often referred to by the more revealing name Female Genital Mutilation).  Comparing FGA to male genital alteration (MGA) reveals some startling differences.  For instance, in the United States MGA can be legally performed for cultural or religious reasons by a non-licensed practitioner outside of a hospital and without analgesia.  FGA, however, cannot be legally performed in the United States for any reason.  Clearly, such a double standard puts a strain on the First Amendment.  The most significant difference between MGA and FGA is the fact that FGA covers a range of procedures, many of which are harmful and appalling.  Since a double standard should not be allowed to persist, and since most forms of FGA should not be permitted, more control ought to be exercised over MGA.  Suggestions are offered in the last chapter of part one to this end.

The topic of part two is sex assignment and reassignment surgery.  First, the question of assignment–what ought to be done when a child is genetically one sex but has the genitalia of the other sex?  Alternately, what ought to be done when a child is born with both male and female genitalia?  Intersex conditions such as these seem to demand some surgical intervention.  After all, intersex conditions can be harmful.  Intersex children can suffer from medical problems like urinary tract infections, infertility, early or late puberty, sexual problems, and risk of cancer.  Social and psychological problems are also common in such cases.  Standard practice calls for a decision to be made by an intersex child's parents concerning which sex they want their child to be.  Questions exist, however, about the child's autonomy and well-being.  By assigning a sex, do we take away a choice that ought to be made by the child (when, of course, a sufficient level of maturity is reached)?  On the other hand, by not assigning a sex, do we thereby take away a child's choice to not be stigmatized as a child?  The primary question, and the one for which few answers (by way of empirical evidence) exist, is this: does early sex assignment surgery result in more harm or more benefit for the intersex child?

Now, the question of reassignment–what should be done when a person of one sex claims to be trapped inside the body of the opposite sex?  Treatment for transsexualism, as such a disorder is called, can involve surgery to alter a person's body so that it more closely resembles the sex a person identifies with.  But such surgeries are controversial largely because transsexualism is not a universally recognized disorder.  Even those who recognize this as a disorder do not all agree that the proper treatment should involve alteration of the body.  It may be, after all, a problem of the mind.

In part three the issue of separating conjoined twins is discussed.  One issue associated with this type of surgery revolves around human well being and flourishing.  Some of those who are against the standard practice of separating conjoined twins claim that being conjoined is merely a difference, not a disorder, disability, or impairment.  Although there is some question as to just how much weight we should give self-reports of well being, one suggestion is that we believe conjoined twins who say that their lives are as full and value-filled as anybody else's.  According to such testimony, conjoined twins enjoy many of the same things and activities that we normally take to constitute flourishing.  However, it is not clear how much more difficult it is on average for a conjoined twin to flourish in these ways than it is for a singleton (if it is more difficult).  And it is not clear how different such difficulty might be from that experienced by those with conditions more commonly regarded as disabilities.  Others will say that being conjoined necessarily makes flourishing more difficult.  And if this is the case, then being conjoined is a disability.  This other side of the coin does not necessarily mean that separating conjoined twins is always preferable to refraining from separating.  Rather, the idea is that the argument for non-separation from difference (as opposed to disability) is a weak one.

Another issue that comes up in this context involves the claim that conjoined twins have a moral and/or ontological status that is quite different from that of other children.  But consider the vagueness of the concept 'individual'.  What is the proper way to speak of conjoined twins?  As two (connected) individuals?  Or as one, albeit an unusual one (in the sense of uncommon)?  And what of the idea that being conjoined is part of every conjoined twin's essence and identity?  This idea makes sense on a psychological understanding.  But to think of being conjoined as an essential part of some humans–and, thus, of some ontologically unique individuals–seems questionable.  Again, the claim being made is that positing an ontological category distinct from that of normal (statistically speaking) humans makes for a weak argument against separation.

The comparison of costs and benefits is a central theme in part four, which deals with limb and face transplants.  One of the primary concerns (and costs) associated with both procedure is the lifetime of taking immunosuppressive drugs in order that the transplanted body part is not rejected.  In addition, there are the costs associated with the surgeries itself.  As many of us have been told, there exist risks with even the most minor of procedures.  On the other hand, there are benefits.  Regaining the use of a missing limb or part of a face is commonly advanced as the benefits of these surgeries.  But some doubt whether or not these benefits can outweigh the serious risks involved.  Indeed, there is evidence suggesting that the recipients of new limbs or faces do (or would) not enjoy nearly the level of capability one would normally enjoy (i.e., one who had the use of her limbs and face).  But perhaps this is not the main concern.  Perhaps the physical pay-offs of a limb or face transplant are secondary to the psychological, emotional, and social pay-offs.  One's self-image and self-esteem stand to benefit greatly from these surgeries.  Although there is some question as to who ought to make the cost/benefit assessment (patient or doctor?), there is no doubt that the improvements to a transplantee's quality of life are not limited to the physical benefits.

Part five offers two defenses of cosmetic surgery.  The difference between cosmetic surgery and reconstructive surgery is somewhat blurry.  The latter is usually understood as a therapeutic response to some injury or other disfiguring event (e.g., a facial transplant for a burn victim).  The former usually involved no such injury.  Some might say that being born with a seriously disfigured arm calls for reconstructive surgery.  They might also say that being born with an unusually large nose is a similar condition which calls for a similar kind of surgery.  Others would argue that having a large nose is not like having a disfigured arm at all, and, if treated, is treated with cosmetic surgery.  In any case, the defenses put forth here involve an understanding of cosmetic surgery as the surgical alteration of a person's body for reasons other than a response to injury.

One way to defend cosmetic surgery is to argue that some instances of it are undertaken for more than purely appearance-related reasons.  It may be a necessary part of an actress' job, if she is to be competitive in her chosen field (though one might wonder if, in such a case, we are talking about purely cosmetic surgery).  Another way to argue is to attack the notion that people (particularly women) are coerced by societal pressures to undergo cosmetic surgery and that, as a result, they don't make an autonomous decision regarding the surgery.  No doubt, there are such pressures.  But a person's decision to undergo cosmetic surgery and thereby act in accordance with society's pressure does not automatically rule out autonomous decision.  'Acting in accordance with' is not the same as 'acting because of'.

Another defense of cosmetic surgery focuses on feminist rejections of it.  Feminists of the 1970s and '80s tended to see cosmetic surgery as an acceptance of male-imposed gender roles, a giving-in or sorts.  Nowadays, some feminists (as well as others who think about these things) see cosmetic surgery as an expression of power, a way to enhance and enjoy sexuality and femininity.  Motives and desires being notoriously difficult things to understand and explain, it is tough to say who's right.

The last part, part six, deals with the highly controversial practice of placebo surgery.  The placebo effect is widely known (if not precisely understood) to be effective in drug trials.  The use of placebos in drug trials is not uncontroversial, but it is not as contested as the use of placebo surgery.  The latter involves at minimum the use of anesthesia and the cutting of flesh.  These both carry risks.  The issue may come down to the difference between good science and good ethics, but even this involves a cluster of other issues.  Principally among these is the matter of a doctor's obligation to do no harm and to act in a patient's best interest.  Whether or not it is morally acceptable to treat people as test subjects instead of patients in the interest of advancing scientific frontiers is a perennial problem in medical ethics.  It is certainly one of the central issues in the context of placebo surgery.

Cutting to the Core is an interesting and enlightening book.  While some of the authors in this collection do not offer definitive conclusions for or against a particular surgery, all do a very nice job of laying out the issues involved in the surgical procedures discussed.  And in light of that, I regard the book as a valuable addition to my bioethics library.

© 2007 Andrew Brei

Andrew Brei is working on a dissertation entitled "Our Right to Health and Our Duty to Nature," and expects to receive his Ph.D. in philosophy in 2007.  In the meantime, he teaches ethics at Purdue University.

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