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Artificial Intelligence in Cosmetic Surgery: Potential Ethical Challenges

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We live in a world where artificial intelligence can predict an individual’s age by

scanning their facial features, all in a matter of seconds. Motion sensor programs can predict

optimal surgical outcomes more accurately than surgeons themselves. Computers compile

hundreds of images and are able to determine overall attractiveness better than humans. Surgeons

then take this data and determine whether cosmetic surgery would make a noticeable difference.

The utilization of these new resources raises a point of discussion internationally amongst

leading plastic surgeons, psychologists, and computer scientists. An examination of the

relationship between artificial intelligence and cosmetic surgery reveals ethical issues through its

application that may alter the integrity of the medical field.

Artificial Intelligence itself prompts many ethical discussions. For those who are

unfamiliar, artificial intelligence is the ability of a computer to present traits such as learning and

reasoning that are typically found in humans. These skills can take on many forms, but AI can

demonstrate problem-solving strategies and achieve detailed goals (Ryu et al., 2021). With this

technology, health care providers are able to construct massive databases of information that they

can apply to their work (Pearson, 2020). Because of these huge movements in healthcare, many

are taking a closer look at the ethical issues that arise from artificial intelligence itself.

One of the most intriguing parts of artificial intelligence is its ability to generate ideas

humans could never think of on their own. In many fields, AI is amazing technology that helps

us overcome human error. In healthcare, artificial intelligence presents some challenges. For

example, an AI program may suggest a procedure that’s entirely successful, and yet never

previously considered by professionals in the field (Ryu et al., 2021). While this does open doors

for new medical procedures, it may not be possible for many surgeons to execute. Many

surgeons spend years perfecting their technique and naturally form preferences. They may have
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learned how to perform a surgery one way when they were in their residency, but AI

recommends a new method of performing it. Even though there is always room to grow and

learn new skills, many professionals use techniques that are just as effective and in their comfort

zones. When artificial intelligence determines the optimal outcome, sometimes it’s not truly the

best procedure for that specific physician to perform.

Artificial intelligence also many not provide the best answer for the patient. Because

artificial intelligence, despite its intellect, is simply a computer system and it is unable to nurture

or feel compassion (Ryu et al., 2021). Patients deserve a physician who is able to understand

their lives, their stories. Often, patients have concerns outside of their physical health. This can

take on many forms such as time off of work, financial struggles, families to provide for,

etcetera. Artificial Intelligence is not in a place, as of now, to cater to these concerns. For many,

these outside influences take priority over their own well-being (Ryu et al., 2021). If a patient

cannot receive care with these accommodations, they likely won’t receive care at all. Because AI

alone is unable to adapt to these concerns, it is unable to provide the best recommendations and

care for the patient.

Artificial Intelligence is also incapable of considering conditions outside of the task at

hand. For example, if a system has been programmed to produce the most optimal outcome for

rhinoplasties, it likely won’t consider other conditions that may affect the outcome. This is

especially apparent in plastic surgery with individuals that experience BDD, or Body

Dysmorphic Disorder (Sun & Rieder, 2021).. Those affected by BDD find flaws in their physical

appearance that others either cannot see or appear quite minimal to them (Sun & Rieder, 2021).

Some initial studies in adult women with BDD seeking cosmetic surgery suggested that surgery

could reduce BDD symptoms (Sun & Rieder, 2021). After this information was published, it was
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quickly disproved. Studies revealed that these image issues simply shifted from one body part to

another. Many developed new appearance issues within 5 years of their surgery (Sun & Rieder,

2021). One study revealed that only 2.3% of cosmetic procedures in BDD adults resulted in

lasting improvements for their disorder (Sun & Rieder, 2021). Knowing this, it is important to

provide BDD screening and education for cosmetic surgeons to better identify BDD patients.

Identifying this condition would be incredibly difficult for artificial intelligence to identify

because BDD presents itself differently in everyone. Physicians would likely be more successful

in detecting BDD in patients, compared to artificial intelligence.

Plastic surgery also presents its own set of ethical challenges. There is an ongoing debate

regarding whether or not cosmetic surgery aligns with the goals of medical practice. Dr. Daniel

Callahan, known for his development of the biomedical ethics we use today, identified four goals

of medicine. These are as follows: prevention of disease and injury and the promotion and

maintenance of health, the relief of pain and suffering caused by maladies, the care and cure of

those with a malady and care of those who cannot be cured and avoidance of premature death

and the pursuit of a peaceful death (Aquino, 2020). In order to abide by these goals, plastic

surgeons have started to pathologize ugliness (Aquino, 2020). This means that plastic surgeons

are taking physical features that are typically considered ugly by society and presenting them in a

way that expresses a diseased condition in need of medical treatment. The term “deformity” has

been frequently used to justify performing cosmetic surgery to the general public, the American

Medical Association, and American Board of Surgery (Aquino, 2020). This language has been

used in a number of different cases, but some examples would be cheek implants, cellulite

treatment, or rhinoplasties (Aquino, 2020). If the cosmetic surgery industry utilized AI databases,

they could program them to identify specific features to be classified as unattractive. This could
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further convince patients that a procedure is not only for aesthetic purposes, but also would

provide treatment.

When marketing cosmetic procedures, surgeons use strategies that highlight the benefits

of the procedures but downplay invasive surgical procedures. These marketing tactics are

extremely effective, but at the expense of the patient. They convince patients that procedures

aren’t only desirable but medically necessary (Aquino, 2020). The private health care market has

known to promote financial gain (Aquino, 2020). By prioritizing their wallets over their patients,

the goals of medicine aren’t being followed, let alone respected. If these companies implemented

AI databases into their work, it would project this issue onto a much larger scale. More patients

would be diagnosed with cosmetic deformities, and in turn, healthcare companies would gain

financially.

When combined, artificial intelligence and cosmetic surgery present an entirely new set

of ethical challenges. One of these challenges has been in regard to the large AI data sets

developed in western and wealthy eastern countries. These cultures have a different perception of

beauty than others, and this may cause the marginalization of others values and perceptions

(Jarvis et al., 2020). Using these data sets in cosmetic surgery could result in surgeons copying

and pasting typical western beauty standards onto all of their patients. While the world has made

large strides towards diversity, these databases could cause white-washing and steps taken

backwards. One example of this can be observed from the 2013 Miss Korea pageant. This

pageant caught international media attention because all of the participants looked strikingly

similar to one another (Jarvis et al., 2020). While one might argue that their resemblance was a

coincidence, but this is actually the result of beauty standards and cosmetic surgery. South Korea

has the highest plastic surgery rates in the entire world, so it comes as no surprise that it is being
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utilized in the pageant world (Jarvis et al., 2020). By using artificial intelligence in plastic

surgery, it may propagate the racial divide and further whitewash the ideal beauty standard.

Combining artificial intelligence and plastic surgery also compromises the patient-

physician relationship. Any conversation between doctors and patients is sensitive and complex.

When body image and aesthetics are added into the mix, it causes patients to be quite vulnerable

and discuss their insecurities. These are conversations that a computer will never be able to have

with the patient. While artificial intelligence has the ability to “learn” and adapt to new

circumstances, it is incapable of identifying deeper mental or physical issues that would lead to a

safer, less invasive solution (Jarvis et al., 2020). It also isn’t capable of recognizing outside

influences that are affecting the patient’s decisions, such as a pressuring spouse or family

member (Jarvis et al., 2020). Artificial Intelligence simply cannot engage in a higher level of

conversation needed to empathize, build trust, and obtain consent from the patient.

Despite challenges, the collaboration of artificial intelligence and plastic surgery would

greatly advance the medical technology currently in practice. This partnership can make

procedures more cost-effective, safer, and more efficient (Murphy & Saleh, 2020). To be

effective, security and high ethical standards must be maintained and consistently tested. One of

the keys to success is the collaboration between computer scientists and physicians. To achieve

this, clinicians should have control over how much artificial intelligence is being used in their

day-to-day work. Computer scientists are unfamiliar with healthcare objectives. This creates a

spot for physicians to partner with them and express their concerns, preferences, needs, etcetera

(Murphy & Saleh, 2020). In addition to maintaining high ethical standards, artificial intelligence

systems must be unbiased, or they will be ruled as unreliable. If surgeons choose to use artificial

intelligence in their work, they are responsible for the decisions it makes. Murphy and Saleh
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state that if clinicians make decisions based off of unsuitable data “patients may undergo

procedures without providing fully informed consent, which risks compromising patient

autonomy” (Murphy & Saleh, 2020). If physicians remain involved in patient care, they would

be able to uphold ethical standards.

The human element of healthcare can never be removed. To truly obtain informed

consent, a physician needs to communicate with the patient. Informed consent isn’t solely about

receiving a yes or no answer. A patient must be in a capable state to provide consent, have been

presented all of the facts and side effects, and express that they understand all of the information

presented to them in both verbal and written forms (Murphy & Saleh, 2020). This ensures that

unwanted surgeries are not performed, because the patient has been proven to be willing and able

to agree to the procedure. Artificial intelligence will never be able to obtain this consent at the

level a physician can.

Additionally artificial intelligence will never possess a “gut feeling” like a human being

can. Many cosmetic surgeons and medical providers have impeccable intuition, due to years

spent learning and working in the field (Murphy & Saleh, 2020). Intuition helps medical

providers identify outside factors that could potentially be pressuring patients to get cosmetic

surgery. This can present itself in many forms such as pressure from family, media, and work

(Murphy & Saleh, 2020).. Intuition, paired with field experience and medical knowledge, can

identify many physical issues too. By building bonds with patients, physicians are able to tell

when “something isn’t quite right” (Murphy & Saleh, 2020). Artificial Intelligence only knows

how to work with the facts presented to its software. It will never be able to sense when

something seems off or when a patient may need care from another field of medicine. If
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physicians use artificial intelligence solely as a tool, they would still be able to utilize their

intuition when necessary.

A partnership between cosmetic surgery and artificial intelligence allows for a whole new

world of possibilities. Artificial Intelligence provides a cost-effective, efficient solution that can

reduce human error. Human-led health care can allow for a more hands-on experience where

trust can be built, and computer error can be reduced (Murphy & Saleh, 2020).. This way,

physicians can still be responsible for the ethical decisions made by themselves and the artificial

intelligence equipment they are using. By incorporation collaboration, the healthcare field can

provide more effective and safer treatment than ever before.

Many wonder what the future holds for plastic surgery and artificial intelligence. The

current technology is quite simple, but there is potential for reduced time under anesthesia and

shortened recovery (Pearson, 2020). This could reduce many risks we face from surgery today.

Scientists and other professionals are unsure of the financial benefits that will emerge from this

new technology, but it will be possible to measure in the years to come. Scientists also are

hopeful that artificial intelligence will accelerate our understanding of disease pathogenesis and

genetics (Pearson, 2020). This will help the plastic surgery industry tremendously in areas that

currently lack information. Some examples of future developments could include identifying

optimal margins for skin cancer excisions and predicting potential surgical failures before they

occur (Pearson, 2020). This partnership will continue to make tremendous strides in medicine for

many years to come.

Going forward, it is the responsibility of the healthcare system and those who practice

within it to ensure the partnership of artificial intelligence and plastic surgery follows all ethical

standards and guidelines. If a patient-first approach is maintained, this partnership provides great
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potential for growth. Regardless of possibilities, the implementation of artificial intelligence in

plastic surgery presents ethical challenges that could change the industry forever.
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References

Aquino, Y. S. (2020). Is ugliness a pathology? an ethical critique of the Therapeuticalization of

Cosmetic Surgery. Bioethics, 34(4), 431–441. https://doi.org/10.1111/bioe.12721

Jarvis, T., Thornburg, D., Rebecca, A. M., & Teven, C. M. (2020). Artificial Intelligence in

plastic surgery. Plastic and Reconstructive Surgery - Global Open, 8(10).

https://doi.org/10.1097/gox.0000000000003200

Murphy, D. C., & Saleh, D. B. (2020). Artificial Intelligence in plastic surgery: What is it? where

are we now? what is on the horizon? The Annals of The Royal College of Surgeons of

England, 102(8), 577–580. https://doi.org/10.1308/rcsann.2020.0158

Pearson, D. (2020, December 17). 4 ways AI may change plastic surgery. AI in Healthcare.

Retrieved November 13, 2021, from

https://aiin.healthcare/topics/emerging-technologies/4-ways-ai-may-change-plastic-

surgery.

Ryu, J. Y., Chung, H. Y., & Choi, K. Y. (2021). Potential role of Artificial Intelligence in

craniofacial surgery. Archives of Craniofacial Surgery, 22(5), 223–231.

https://doi.org/10.7181/acfs.2021.00507.

Sun, M. D., & Rieder, E. A. (2021). Psychosocial issues and body dysmorphic disorder in

aesthetics: Review and debate. Clinics in Dermatology.

https://doi.org/10.1016/j.clindermatol.2021.08.008