Cosmetic Limb Lengthening: Ethical Considerations

• A 23-year-old male patient underwent cosmetic limb lengthening, despite being of average height for an Indian male (5 feet 7 inches).
• The orthopedic surgeon was criticized by the patient's parents and the media for performing an unethical operation.
• The paper argues the surgeon's decision was fair and appropriate after discussing clinical evidence, ethical aspects, and ethical theories.

Introduction

• The llizarov external device is usually used to lengthen bones shortened by trauma, infection, non-union, or congenital conditions.
• A controversial limb lengthening surgery in Hyderabad was performed on a young man of 5 feet 7 inches, considered above average height for an Indian male.
• The nationwide debate questions the ethicality of the procedure, with the newspaper suggesting the patient's parents should have been consulted since the patient was only 23 years old.

Current Clinical Evidence

• One study focusing on cosmetic limb lengthening among individuals of normal height and two additional papers with cohorts described individuals of short and normal height.
• The mean patient height was 170 cm, with an upper limit range of 174-176 cm.
• 215 patients underwent cosmetic leg lengthening.
• Patient's mean age ranged from 25 to 27 years.
• Ring fixator type devices were used for complete leg lengthening, while the Ilizarov device was replaced by an intramedullary nail in one study.
• The mean height gained was from 6.9 cm to 7.6 cm.
• Outcomes were excellent to good in 95%-100% of patients.
• 94%-99.2% of patients were satisfied with the procedure.
• 96%-99.2% were willing to undergo the surgery again and recommend it to others with subjective feelings of being short.
• The re-surgery incidence ranged from 12.5% to 28%.
• Leg lengthening with the Ilizarov device has been performed on individuals of normal and short stature so cannot be dubbed "unusual experimental surgery".

Principles of Ethics

• "Bio-ethics" are the written and unwritten rules that medical professionals follow, as they are considered standards.
• Ethics account for clinical factors, non-clinical factors, ethical factors, and rules laid out in the code of conduct published by the Medical Council of India.
• The four principles of ethics are respect for patient autonomy, beneficence, non-maleficence, and justice.
• Respect for autonomy involves respecting the patient's decision, meaning mature adults can make their own decisions without doctor pressure.
• Informed consent is obtained from patient after explaining the risks and benefits of procedures, as well as the other choices that are available.
• The non-operative alternative choice would be a shoe raise fitted.
• Doctors must take the wishes of the patients seriously and respect the patients confidentiality.
• Denying a height gain surgery to a patient violates the patient's right to autonomy.
• Beneficence means acting in the patient's best interest.
• The surgical procedure should benefit patients.
• Cosmetic limb lengthening surgery not only increases the height of patients, it also improves their self-esteem.
• Refraining from doing any harm to the patient is non-maleficence.
• Benefits of intervention must be greater than risks involved.
• There should not be any malafide intentions when undergoing the surgical procedure.
• Complications of limb lengthening surgery range from 37% to 72%, and mostly involve soft tissue and bony parts, but are of a mild nature.
• Justice involves fair and appropriate resource allocation.
• Justice also means a decision must benefit both the patient and society.
• Private healthcare allows the patients to pay for and choose their surgery.
• There are no laws that determine cosmetic limb lengthening should not be undertaken in the country.
• Deciding to perform surgery for height gain in patients who subjectively feel that they are of short stature is in accordance with the four basic ethical principles
• Denying the surgery to a patient who requests it for a valid and reasonable cause violates all four principles.

Ethical Theories

• When encountering a complex ethical question, it is advisable to evaluate the question using different ethical theories.
• Utilitarian doctrine states that an act is justified only when it maximizes the "happiness" of society.
• Irrespective of rich/poor, short/normal stature, everyone is given equal importance.
• The utilitarian outlook states that there is only one right act in a situation.
• An act is is right or wrong depending on the final consequence.
• The final outcome is given more importance than the means to reach the outcome.
• If patients achieve the height wanted, they are likely to be satisfied with the outcome.
• Limb lengthening is right, if the patient is satisfied.
• One is likely to obtain an answer to whether the surgical intervention has been satisfactory at the end of one year or 18months after the intervention.
• Duty-based moral theories state that an act is justified only if it is in accordance with moral values, against the background of rationality.
• There might be more than one right act in a given situation.
• The nature of the act is more decisive than the final consequence.
• A shoe raise is a non-operative option, that would entail wearing shoes at all times.
• After discussing the option with the patient to find a permanent solution, the only remaining option for skeletally mature individual is surgical limb lengthening offering surgical limb lengthening is a reasonable option.
• Virtue ethics states that an act is right if a virtuous person would act similarly in a similar situation.

Consent for Surgical Intervention

• Mature adults above 18 can make independent decisions regarding surgical procedures that they wish to undergo.
• The consent of parents is not mandatory.
• Consent of parents or legal guardian is required for patients below 18 years of age.
• Mature adult patients are required to inform their families, relatives or friends about procedures.
• Maintaining the patient's confidentiality is of the utmost importance.
• Patients with doubts regarding their psychiatric health may not be fit to take this procedure.
• Doctors can advise patients to bring family members for a clinical interview.
• The patient has the final say as to whether the family members should be involved in the decision-making process.
• Documenting this in notes can save the doctor from an embarrassing situation in future.
• Importance of contemporaneous documentation cannot be overemphasized.
• A signed consent form should mention the benefits, possible problems, and complications of the procedure.
• Determining the patient's reasons for wishing to undergo limb lengthening surgery despite being 5 feet 7 inches should be done.
• Height requirements required for participation in specific activities, occupational requirements, or shorter stature compared to other men in his community should be accessed.
• It is important to know the patient's final height.
• Achievement within particular/reasonable limits is something to access.
• Preoperative counseling could have been of use should there by unreasonable expectations.
• The 3 inch height increase (7.6 cm) is aligned with reasonable height achieved.

Suggestions for the Future

• Assess patients by a psychologist to ensure that their perceived short stature is affecting them psychologically.
• The perceived short stature must be severe enough to affect the person's mood most of the time.
• Patients with dysmorphophobia cannot make sensible judgements and give legal consent.
• Detailed preoperative assessment can help rule out dysmorphophobia or any other kinds of psychiatric illnesses.
• Psychological evaluation by a psychologist was performed as a part of the preoperative evaluation in studies.
• Ruling out psychological disorders such as dysmorphophobia is important.
• One study states the psychologist only recommended height gain surgery in 52 (50%) of 104 patients (4).
• In the case of discussion, is unclear whether the subject underwent a detailed psychological eval.
• Psychological evaluation helps to understand why the patient wants to undergo cosmetic height gain surgery.
• Previously published studies have utilised psychological evaluation.
• Specifying psychological evaluation in India is advisable as jobs, community, or certain relationships may require a person to have a minimum height.
• Reasons considered must be valid, and it is up to the treating surgeon to consider their validity.
• There is need to document if a patient tells the doctor that their families must not be informed within the case notes.
• Patients signing a special consent form will save the surgeon from embarrassing questions from the family.
• Family involvement was specifically mentioned in only one study (3).
• Having several clinical encounters is better than making a single decision based on the first clinical interview.
• Evaluating whether the intention/sincerity of their leg lengthening intentions will be sincere and informed is necessary.
• Videotaping and saving informed consent would prevent issues.
• Applying the rigor of funded clinical trials to uncommon elective and planned surgeries with legal implication might be a worthwhile idea.
• Suggesting interviews with patients (2, 4) is beneficial.
• Arrange interviews between a prospective patient and a person undergoing leg lengthening surgery, the final outcome provides reassurance.

Ethical Dilemmas

• It is important to appreciate the differences in the outlooks of different societies.
• Western countries are individualistic, whereas Indian society continues to have a collective outlook.
• The newspaper article mentions the patient's father having objections.
• The patient worked in IT and has an independent financial outlook.
• Patients in India have differing points of views.
• Is it ethically appropriate for newspapers and journals to take a stand against the patient and the orthopaedic surgeon?
• Ethics should be isolated from culture and society.
• The ethical theories and points supporting the doctor's view originate predominately from the West.
• If we carried out a survey on civil society in India, they may not have agreed supporting the ethics, and it would global criticsm.
• Developing theories of bioethics in Eastern countries is beneficial, as their worldview creates ethical challenges.
• Applying bioethics theories in the West leads to dissatisfaction among many.
• In India, people trained in the West give ethical guidelines, which applies to even the MCI's code of ethics.
• Developing our own theories of ethics should occur, as there will always be a schism between the textbooks and what is felt as being ethical.

Conclusion

• The independent review of the case has been put under ethical scanner, which uses only the information extracted from the news paper.
• The report can show potential missing information.
• The good outcomes shows that patients whose height is normal and who have subjective feelings of being short shows great benefits from limg lengthening.
• Risks and complications are minimal, but the benefits/problems is not a permanent disability. However, the different ethical theories supports different decision making.
• The surgeon's decision to perform the surgery seems to be fair and appropriate from the ethical and clinical perspectives.