Breast Reconstruction and the Patriarchy: When Surgeons Ignore Patient Wishes

Hubris at its ugliest

Welcome back Chaise Lounge readers and an especially warm welcome to our newest subscribers! This week we will delve into the murky world of breast reconstruction surgery and how patriarchal attitudes seep into every part of a woman’s choices. Please leave your reaction to this piece in the comments or feel free to respond by email. I am curious to hear your thoughts, as usual. But first, a look at some other news.

Global News

The Australian Air Force has changed their term from “airmen” to “aviators” in a tacit acknowledgment that 20% of the aviators are not men. While the leadership did not specifically say their reason for the change, a more inclusive title is always good news.

Australia is getting rid of laws that protected public sector employers, including judges, from sexual harassment claims. Changes include a blanket ban on harassment due to gender and mandatory training and reporting.

Su Min, a 56-year-old Chinese woman has had enough of taking care of everyone else. During the pandemic, she has been on a months-long road trip exploring many parts of China and is reveling in doing something just because she wants. to. She is an internet star with thousands of followers wishing her well and identifying with her wanderlust.

National News

Interior Secretary Deb Haaland announced the formation of a new “Missing & Murdered Unit (MMU) within the Bureau of Indian Affairs Office of Justice Services (BIA-OJS) to provide leadership and direction for cross-departmental and interagency work involving missing and murdered American Indians and Alaska Natives.” If you haven’t already read my articles about this topic, please take a look. This is excellent news as coordination between federal agencies has been lacking for decades.

President Biden’s infrastructure plan includes provisions to bolster the “care economy”. While this part of the plan has received Republican backlash, the administration points out that if we don’t have strong care at home for small children and the elderly, many cannot work and contribute to the economy.

One piece of news from the NCAA women’s tournament did not happen on the court but in the locker room is interesting and illuminating. Arizona head coach Adia Barnes was a little late coming out for the second half because she spent that time pumping breast milk for her six-month-old baby. Now I know that is something that Roy Williams never had to do!

Breast Reconstruction and the Patriarchy: When Surgeons Ignore Patient Wishes

Patients who undergo surgery, chemotherapy, and/or radiation treatment for breast cancer endure an intense amount of medical intervention. If they decide that they want to have breast reconstruction surgery, the last thing on their mind is the possibility that their surgeon will not honor their wishes. As awful as that sounds, it happens more often than you may think.

In actor Sharon Stone’s newly published memoir The Beauty of Living Twice, she reveals that in 2001 she underwent reconstructive breast surgery after having large, benign tumors removed from her breasts. When she unwrapped her bandages, she realized that her surgeon had given her implants that were a cup size larger than they had agreed upon. When asked why he did it, he told her that he thought the ones he implanted “go better with your hip size.” 

And it turns out that her case is not rare in the reconstructive breast surgery world. I have a personal friend, Clara*, to whom this happened. According to Clara, in their discussions before the surgery, she told the surgeon, ”I’m going in as a B and want to come out as a B.” When she came out of surgery, she found that her surgeon had given her DD cup implants. Now, if you are not a woman, you may not understand the implications of this size jump, but Clara is an athlete and did not want to have to manage large breasts for that specific reason. When she asked her surgeon why he gave her DDs, he told her that because she is tall, they would look better. 

In 2016,  Kim Bowles told her surgeon that she did not want reconstruction surgery and wanted to be flat. This was not a case of miscommunication. She wrote him a letter, brought photos and a witness to her appointments with the surgeon. Yet, the surgeon decided that he knew better and left two large flaps of skin in case she changed her mind. Of course, Ms. Bowles was upset not only to not have her wishes followed but faced having to go through another procedure to get what she wanted after already enduring cancer treatments. Ms. Bowles’ case is not a unicorn. According to a study in the Annals of Surgical Oncology, many doctors do not offer going flat as an option and/or push patients toward reconstructive surgery, even when the patient is clear as to what they want. Others ignore the patient's wishes, as Kim Bowles’ doctor did, and leave flaps because they cannot believe that a woman would want to be flat. 

For all of these women, their male doctor’s explanation was that he knew better and thought that the bigger breasts matched her figure better. Or, in Ms. Bowles’ case, you don’t really know what you want. Read: The male gaze is more important than what you want for your body. Or: I am a surgeon, so I know better than you what is correct for your body. When Clara told me about her experience, I was dumbfounded and furious on her behalf. The idea that a doctor would go against a patient’s express wishes on something as important as the body you live in each and every day is mind-bogglingly cruel. It is tantamount to assault. 

My first question was, doesn’t this go against medical ethics? The answer is a resounding yes! According to a systematic review of medical ethics in plastic surgery by the National Institutes of Health, the most widely adopted ethical framework for decision-making is based on the four moral principles of autonomy, beneficence, nonmaleficence, and distributive justice (see table below). This framework is commonly taught in foundational courses in medical ethics. 

Beauchamp and Childress' four ethical principles and how each pertains to plastic surgery

If we look at each of these ethical areas, we can see where the doctors discussed in each of the cases above fell down on the job. 

Autonomy - The doctors described did not respect their patient’s right to self-choice and self-governance in making their own decisions. 

Non-Maleficence - While the doctors did not do anything that would cause serious physical harm to the patients, the patients have to live with sagging pouches of skin or large breasts that they did not want. This causes psychological harm. It is maleficent to perform a surgery in a manner that you know goes against the wishes of your patient for no medical benefit.

Beneficence - It’s hard to say that a doctor acted in the best interest of the patient when they performed surgery in a manner without their consent.

Distributed Justice - Women who have undergone cancer therapies prior to reconstructive surgery, are typically in debt due to high medical costs. They are not able to afford another surgery. Who knows if any insurance company would approve a second surgery considered cosmetic in nature if they already paid for the reconstruction surgery. 

Women who have completed their cancer treatments are already in a vulnerable place when it comes to surgeries that have corrupted their bodies and self-image. By the time they are making decisions about whether or not they want reconstruction and what size their breasts should be, they have been through a year-long traumatic experience. Their surgeons should do their absolute best to make sure that they are completing a surgery with an outcome closest to what the patient desires.

Doctors bring their own prejudices

In research around doctor/patient communication, we see that doctors come to the table with assumptions that are flat-out wrong at times. For example, when it comes to breast surgery for cancer patients, 71% of doctors thought that breast preservation would be a patient’s number one priority when in actuality, that number is only 7%. Perhaps this disconnect is at work in the minds of these surgeons.

What can a patient do?

I spoke with Dr. Joanna Hooten, a dermatologist who performs cosmetic treatments, who suggests that surgeons “include the patient’s wishes in the informed consent that the patient signs.” If the doctor and patient agree on a course of action for the surgery, then there is no reason not to put that information in the informed consent agreement. Of course, sometimes situations come up in surgery that makes it impossible for things to turn out exactly the way they were planned, and that can be included in the consent as well. But we are not talking about normal surgical uncertainties. We are talking about surgeons who take it upon themselves to change a woman’s appearance against her wishes while she is unconscious. Perhaps if the doctor knows that the patient’s wishes are legally recorded in the consent agreement, he will take a moment to think about the possibility of a lawsuit if he decides to change to surgical outcome. More importantly, we hope that the doctor will understand that when they complete an unwanted surgery on a woman, they are committing assault.

*Clara is a pseudonym to protect her privacy.

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