Larcombe, Wendy --- "Cosmetic Surgery, Choice and Regulation" [2010] UMelbLRS 22

Last Updated: 24 May 2012

Cosmetic Surgery, Choice and Regulation
Dr Wendy Larcombe*

Paper presented at the Inaugural Australasian Association of Bioethics and Health Law Conference, 1-4 July 2010, Adelaide.

Abstract
The calls for stronger regulation of cosmetic surgery (or cosmetic medical practice) in Australia are loud and clear. The increasing popularity of cosmetic medical procedures over the past decade, the proliferation of providers and techniques, and the high number of claims against professional indemnity insurers in relation to cosmetic procedures indicate the need for an extensive review of existing regulatory mechanisms. In this context, it is timely to consider how regulation of this area of health practice might best be approached. This paper focuses on issues of patient choice and autonomy. It asks: what kind of choice is the decision to undergo cosmetic surgery and how might this impact on both patients’ expectations and doctors’ responsibilities? As most cosmetic surgery patients are women, undergoing procedures such as liposuction and breast augmentation, feminists have often questioned the autonomy of the decision to undergo cosmetic surgery: the freedom of women’s choice(s). Feminist theories of ‘relational autonomy’ have been advanced in this context; this paper argues that they are also relevant to a consideration of how cosmetic surgery might best be regulated precisely because they can focus attention on the relation between practitioner and patient.

Key words: cosmetic surgery, choice, relational autonomy, medical regulation

Introduction
The calls for stronger regulation of cosmetic surgery and cosmetic medical practice in Australia are loud and clear. The increasing popularity of cosmetic medical and surgical procedures over the past decade, the proliferation of providers and techniques, and the high number of claims against professional indemnity insurers in relation to cosmetic procedures indicate the need for an extensive review of existing regulatory mechanisms. In Victoria, the death in January 2007 of 26 year-old Lauren James and in South Australia, the death in March 2008 of 28 year-old Lauren Edgar, both as a result of complications following liposuction,[1] were a stark reminder of the risks associated with some procedures that are routinely marketed as ‘safe and effective’ beauty treatments rather than as invasive surgery. Choice magazine’s 2009 exposure of ‘unprofessional conduct’ within the cosmetic surgery industry, revealed when three ‘secret shoppers’ sought professional advice about common procedures,[2] broadened the concerns beyond medical negligence and poor clinical outcomes to consumer protection from inappropriate sales techniques and finance arrangements, and inadequate procedures for obtaining informed consent.

Both the Australian Society of Plastic Surgeons and the Australasian College of Cosmetic Surgery have joined the calls of consumer groups for ‘greater regulation of cosmetic surgery’.[3] In response, the Australian Health Ministers’ Advisory Council (AHMAC) has established an Inter-Jurisdictional Cosmetic Surgery Working Group (IJCSWG) to review the adequacy of consumer safeguards in relation to cosmetic medical and surgical procedures. Advertising, information provision, informed consent and practice standards will all be considered as part of this review.

In this context it is timely to consider how regulation of this area of health practice might best be approached and the values and interests it would be designed to protect. Given the conference theme, this paper focuses on issues of patient choice and autonomy. It asks: what kind of choice is the decision to undergo cosmetic surgery and how might this impact on both patients’ expectations and doctors’ responsibilities? As most cosmetic surgery patients are women, undergoing procedures such as liposuction and breast augmentation, feminists have often questioned the autonomy of the decision to undergo cosmetic surgery: the freedom of women’s choice(s). More particularly, if we’re interested in the issue of autonomy, we can ask: does a decision to undergo cosmetic surgery reflect the individual woman’s own values and life-goals, or is it the result of oppressive social norms that pressure women to conform to particular, narrow idea(l)s of female attractiveness? I explain the various positions in more detail shortly. Firstly, I’ll preview the direction of the paper.

Feminist theories of ‘relational autonomy’ provide a means for thinking beyond the binary created by on the one hand, regarding all ‘choice’ (by competent adults) as ‘free’ and, on the other, regarding women’s decisions as entirely determined by social norms (oppressive or otherwise). Theories of relational autonomy challenge the rationalistic and individualistic conception of autonomy often employed in bioethics, by attending to the socially constructed nature of all values and goals, and the socially situated and relational nature of agency and autonomy-enhancing capacities. This paper argues that these theories provide useful tools for thinking about the context in which cosmetic surgery is practised, and the ways in which patient autonomy may be enhanced or restricted by current practices within the industry. They are thus also relevant to a consideration of how cosmetic surgery may best be regulated – in particular, because they take us beyond informed consent as a measure of autonomy and focus our attention on the relation between practitioner and ‘patient’ or client.

Cosmetic medical and surgical practice
It is common to define cosmetic medical practice or cosmetic surgery as concerned with ‘reshaping normal structures of the body using surgical and non-surgical techniques’ with the sole purpose of improving the client’s appearance and self-esteem.[4] Strictly speaking, ‘cosmetic medical practice’ refers to non-invasive techniques and procedures while ‘cosmetic surgery’ describes invasive ones. But that distinction is less clear and not particularly meaningful in relation to practitioners – for example, many surgically trained doctors who practice in cosmetics use a range of less invasive techniques and procedures that reduce the need for sedation and anaesthesia, while many practitioners without surgical training perform what might be considered invasive techniques, such as using injections but also procedures requiring incisions.[5] Further, both cosmetic medical and surgical practice include a wide range of techniques and technologies so that practitioners within each grouping may have disparate skills and expertise. For convenience, this paper uses ‘cosmetic medical practice’ or simply ‘cosmetic practice’ as an umbrella term covering both invasive and non-invasive procedures.

Cosmetic practice is thus a distinct area of medical practice, not distinguished by a common set of procedures or the distinct skill set of practitioners but rather by the fact that there is no medical need for the intervention or treatment. Cosmetic practice is generally defined as entirely elective or discretionary and thus ‘private’, receiving no medicare funding, in contrast to reconstructive plastic surgery or other medical treatments which change or improve appearance, but for which there is also a demonstrable health benefit. In short, cosmetic procedures are those performed on the healthy population solely to improve appearance or self esteem. The cosmetic ‘industry’ is sometimes claimed to have developed and expanded in response to consumer demand, but of course that demand itself has developed in response to the marketing of cosmetic medical and surgical services following the relaxation of restrictions on the advertising of medical services in Australia in the early 1990s.[6]

We can note that the distinction between reconstructive or therapeutic procedures on one hand and enhancement or entirely ‘cosmetic’ procedures on the other relies on reference to the ‘normal’ body which is by no means a fixed or ‘natural’ standard[7] – what constitutes a ‘deformity’ warranting medical correction is a matter of perception. However, it is not necessary to engage that debate for the purposes of this paper. What it is necessary to note is that, depending on the procedure, between 80 and 100 per cent of cosmetic surgery consumers are women – for example, the Cosmetic Surgery Report NSW 1999 reported 86% of consumers were female.[8] In that study, liposuction and breast augmentation were the most popular procedures. In the decade since that study, innovations in facial ‘rejuvenation’ techniques using laser resurfacing technologies, and the availability of various dermal fillers as well as Botox, have seen a marked increase in the popularity of these procedures – still primarily among female consumers.

Feminist critiques of cosmetic procedures: choice and autonomy
As forecast, and perhaps not surprisingly, feminists from a range of academic disciplines have been interested in analysing the practice and significance of cosmetic surgery. A central question concerns the nature of the ‘choice’ to undergo cosmetic surgery – is this a ‘free’ choice that demonstrates the individual’s autonomy? OR, in a social and cultural context in which particular, narrow constructions of female attractiveness and body shape act as tropes for desirability and success, does a woman’s ‘choice’ to undergo cosmetic surgery only reveal the extent of the social pressures on women to conform to unrealistic and often punitive gendered norms?

There can be little doubt that the marketing of cosmetic procedures, usually targeted specifically to women, relies on and emphasises the value and importance of appearance for women (often as a measure of imagined sexual desirability to men). The procedures themselves – face lifts, breast augmentation, liposuction, vaginal ‘rejuvenation’ and tummy tucks – reflect and confirm particular social ideals about the attractiveness in women of youth, slimness, a tight vagina and a full bust. But feminist theorists in a range of fields have also recognized in past decades that the existence of particular, gendered social pressures and norms does not necessarily or inevitably preclude individual agency nor diminish a woman’s capacity for self-regarding behaviour. So the identification of gendered norms and social values cannot be the end of the inquiry about choice – to do otherwise would imply effectively that women are never able to make independent and informed choices.

It is at this point that it is useful to go beyond choice to the value that it is often considered to reflect and support: autonomy. Respect for patient choice is promoted within bioethics as a measure of patient autonomy. In turn, autonomy is valued within medicine, as it is in law, as enabling ‘rule of the self’: the idea of self-determination or self-governance which holds as a value the right and capacity of each person to formulate their own goals and desires and determine for themselves what constitutes a ‘good life’ and how they want to live.[9] For many, ‘will’ and self-determination are the defining characteristics of free moral agents and even of human beings. Of course, the legitimate interests of others impose limits on individual autonomy. Autonomy is also compromised in circumstances of oppression and coercion; that is, when the individual’s self-regarding actions cannot be regarded as ‘free’ or voluntary is a meaningful sense. Thus, ‘autonomy’ is general regarded as the capacity or capability to act in accordance with one’s values, desires and goals where these values and desires are themselves a reflection of one’s ‘true’ or ‘higher’ self (and not just the result of oppressive socialisation or unquestioning internalization of social norms).

Relational autonomy
With such an understanding of autonomy it is clear that conventional practices for obtaining informed consent to healthcare procedures are an extremely limited means by which to demonstrate respect for patient autonomy. Beyond asking whether the patient is competent to a minimal legal standard, informed consent has often focused on the actions of the practitioner – in providing information about risks and obtaining a patient’s signature – and not considered the capacities of the competent adult patient to critically reflect on their choices and values within the relevant context and circumstances.[10]

The capacity for critical reflection is generally accepted as a necessary condition for the realisation of autonomy.[11] Self-respect and trust in one’s own capacities for decision-making may also be necessary. Hence, particularly in moral philosophy, autonomy requires critical reflection not only on one’s values and goals but also on the influences and norms which have shaped those values and goals. The second level of reflection and questioning is important to ensure that autonomy-protective measures do not in fact bolster and reinforce oppressive regimes and values.

Feminist philosophers have challenged the common reduction of the concept of autonomy to a form of individualism so that autonomy is seen to be exercised and valued when an individual makes decisions that value independence rather than interdependence and, often, self-interest rather than responsibility to others. Feminists also challenge the conceptualisation of individuals as atomistic agents, capable of being understood in isolation from the social relations and communities in which they participate.[12] Instead, they identify that the concept of the individual as a separate, independent agent is the social being of liberal capitalism – that is, of a particular social and political set of relations, values and beliefs. Others have also contested the notion of the person as psychically unified – as able to know their motives and desires and to be fully self-governing. Postmodern critiques would thus expose the idea of an integrated and regulated ‘self’ as illusory, as itself a means of securing particular relations of power.[13]

As a consequence, feminist philosophers have developed theories of autonomy that are at once more descriptively accurate, and also less normatively masculinist, because they emphasise the social nature of the self. Indeed, theories of relational autonomy understand autonomy as a consequence and value of social relations, rather than a consequence of an individual’s independence. Relational autonomy understands that the values, plans and goals that a person may wish to pursue will be socially constituted – that is, the result of a complex set of social relations and practices which the individual has not ‘invented’; which are not the individual’s ‘own’ in the sense of being entirely original. The opportunities and choices available to a person are also socially produced and determined. In this relational context, autonomy is not achieved by freeing oneself from social influences and values but by a process of reflective engagement with the norms and standards that shape one’s circumstances so that, at least to a degree, the individual actively participates in shaping their own life as their own.[14] This procedural rather than substantive concept of autonomy does not require that an individual continually question and reflect on their plans and values. Autonomy is a competency and practice rather than an absolute;[15] rather than speaking of the individual as autonomous, it is only sensible to talk about degrees of autonomy exercised by individuals in particular contexts.

Those contexts include the network of social relationships in which the individual participates. As Linda Barclay has observed, autonomy-capacity and competencies are themselves social products: ‘The fact that any of us has the capacity for autonomous agency is a debt that we each owe to others’ and, more particularly, often to the work of mothers in socialisation and moral education.[16] Even during the stages of our lives when we are not dependent, we are largely interdependent (rather than independent) and, as Melanie Latham observes, ‘others’ continue to play an important role in enhancing one’s autonomy by enabling the individual to think through and discuss their options and plans in a supportive context:[17] in this way, the self can be understood to be practically as well as conceptually produced and realized in its relations with others.

Relational autonomy and cosmetic medical practice
In thinking about autonomy and cosmetic medical practice the value of relational theories is that they enable us to comprehend the socially constructed nature of the choices available to women, and the social pressures exerted by gender-specific norms and values, without losing sight of the possibilities and opportunities for agency and autonomy. They would also direct us, in considering the latter, to attend to the context in which decisions and actions are contemplated, and to the ways in which social relations and practices may enhance or constrain the development and exercise of autonomy competencies. Most importantly, perhaps, they offer us a procedural account of autonomy, which directs us to the capabilities and decision-making competencies of individuals, rather than a substantive one which would refer us only to the content of particular choices. In relation to cosmetic procedures this is particularly valuable because it prevents over-generalisation and insists that the meaning of procedures - in terms of autonomy - will vary depending on the context, particularly any coercive influences, and the capacities of the individual to reflect on their desires, goals and options.

Even women requesting a single procedure – say breast augmentation – will have diverse reasons and motives for undergoing the surgery, so that the procedure itself does not reveal the degree of autonomy being exercised by the client. For example, a thirty-five year old woman who is desperate to have a child and undergoes breast augmentation at the request of the latest boyfriend in hopes that it will help cement an otherwise lukewarm relationship is not making the same kind of ‘choice’ (in terms of degrees of autonomy) as a 35 year old woman who has completed her family, is in a long-term stable relationship, and seeks breast augmentation because breast-feeding her children has reduced her former C cup bust to what she perceives as a pair of ‘flat balloons’ and she wants the surgery in order to feel more like her former self.

Similarly, however, we can see that the autonomy of the latter client will be affected by the circumstances in which she seeks and accesses advice about breast augmentation. Specifically, if she:

• attends a ‘beauty therapy’ centre after seeing an online add for ‘safe and effective same day breast enhancement’, and
• undergoes her procedure that afternoon
• after signing a credit agreement with a second company to cover the fees,
• without being given detailed or written information about her options and the risks of each, and
• following only a 7 minute ‘consultation’ with the practitioner who performs the surgery

her ‘choice’ will be quite different in terms of the degree of autonomy exercised than if she:

• discusses her desires and intentions with her GP who provides a list of recommended cosmetic practitioners and encourages her to seek two or three separate opinions,
• each of those practitioners spends as much time as she needs exploring her options and their likely outcomes, and discusses how the potential benefits might be weighed against the risks and,
• after further reflection and discussion with her family and friends,
• the woman decides to proceed with the practitioner whose qualifications and experience seem best suited to the selected procedure and whom she trusts to provide comprehensive aftercare and support.
  

Autonomy and regulation of cosmetic medical practice
Theories of relational autonomy enable us to better understand the ‘choice’ to undergo cosmetic surgery. I want to suggest that these theories also provide useful tools for thinking about the context in which cosmetic surgery is practised, the ways in which patient autonomy may be constrained by current practices within the industry, and the ways that it might be enhanced through regulation of cosmetic practice.

Before turning to regulation and autonomy, we can note that, to date, much of the discussion about regulation of cosmetic medical practice has concentrated on measures to improve the safety of this field of practice – for example, through registration and inspection of private facilities where procedures are conducted, prescribing minimum standards for after-care and record keeping, and determining minimum training requirements for practitioners. Calls for stronger regulation have also aimed to ensure that patients are fully informed of the risks associated with particular procedures – by for example, prescribing minimum standards for informed consent and attempting to prevent misleading advertising. Such measures are urgently needed – indeed, what is striking perhaps is that they are not already in place. However, I want to suggest that measures directed to improving (minimum) safety standards and (minimally) informed consent are not sufficient if the aim is to respect and foster patient autonomy. [Indeed there is a risk that such measures may encourage a view that, post-regulation, cosmetic procedures are now ‘safe’ in a way that brings them into line with the mainstream of medical practice such that the consumer or potential client does not need to make their own inquiries and assessment of procedures.]

If an aim of the regulation of cosmetic medical practice is also to enhance the autonomy of potential and actual clients then, as discussed above, regulation needs to consider how it might foster the capacity of cosmetic clients to decide for themselves whether the available treatments will further their desires and goals – that is, deliver what they want – and assess whether the risks are acceptable when weighed against the potential (but by no means guaranteed) outcomes.

In this context, Melanie Latham has recommended regulatory measures including mandatory counselling and cooling-off periods to enable potential clients to reflect on and clarify their goals and desires and the potential of the contemplated procedures to achieve these.[18] However, I would caution that measures such as these can have a tendency to reproduce the old idea, still prevalent within many areas of law, that women are not competent decision-makers. This is not desirable. Such measures may also instil or foster among medical practitioners a belief that cosmetic clients do not know their minds, inevitably have unrealistic expectations and must be approached with special caution – at least if the practitioner is to come through the procedure ‘unscathed’. Thus, while I agree with Latham’s analysis of the need for regulation to attend to the issue of patient autonomy, I don’t support the kinds of measures that she proposes.

Indeed, a limitation of all measures that address either the practitioner (his/her skills and qualifications and the standard of information that he/she provides) or the client (her/his expectations, desires and decision-making processes) in isolation do not comprehend the relation between practitioner and patient. And yet theories of relational autonomy would remind us that it is in such relations that opportunities for the exercise of autonomy are fostered or restricted. In short, they remind us that the basis and conduct of the relationship between practitioner and patient will be significant in determining the autonomy-capacities of cosmetic clients.

With that understanding, I want to suggest that the autonomy of cosmetic clients is currently constrained because the basis of the relation between cosmetic client and medical practitioner is often not clear. Specifically, the ‘doctor’ doubles as ‘health practitioner’ and a ‘commercial services provider’. Yet the former role is highly regulated and credentialed, supported by an extensive evidence base for their practice, and obligated to act in the patient’s best interests. The latter, by contrasts, operates in a competitive marketplace with relatively little regulation and accountability, a limited evidence base for practice and almost no peer review. The client similarly crosses between patient ‘receiving health advice and treatment’ – where the expert judgement of the practitioner as to the need for treatment and its likely benefits is objective and evidence based – and ‘consumer of commercial services’ where the measures under consideration are entirely discretionary and the judgment of the practitioner as to the need for treatment and its likely benefits is subjective, if not irrelevant (given that the perceived ‘need’ and the value of the potential benefits is entirely for the client to determine). Especially when, as in the current environment, a number of medical practitioners offer cosmetic procedures as a private ‘sideline’ to their normal general or specialist practice, there is high potential for confusion on the part of both practitioner and patient as to which ‘hat’ the doctor is wearing when he or she suggests or discusses a cosmetic procedure.

There is a particular risk from this confusion that the deference to doctors and their expertise that is inherent (to varying degrees) in the doctor-patient relationship is transferred to the service provider-cosmetic consumer relationship. If this occurs, client autonomy in the latter context is likely to be impaired. There is some evidence that this is the case. Rhian Parker’s sociological study of cosmetic surgery consumers and practitioners (published earlier this year) found that cosmetic clients are not exercising the consumer techniques that might usually be applied to purchase of commercial services. For example, most women in her study: [19]

• found their cosmetic practitioner through advertising rather than by referral from either their GP or former clients of the practitioner;
• they didn’t routinely ‘comparison shop’ (seek second opinions) or evaluate the qualifications and experience of the practitioner to perform the procedures under consideration, meaning that the recommendations and opinions of the nurses and support staff in the practice were often given significant (and perhaps inappropriate) weight;
• and many women did not discuss their options or intentions with friends and family so that the information on which they based their decisions was largely derived from sources internal to the cosmetic industry.

Given that, in general, women are very skilled and experienced consumers, these findings are perhaps surprising – until we consider the extent to which the lines between medical treatment and cosmetic practice, and the corresponding roles of patient and consumer, are currently blurred.

It is my suggestion that, in order to foster the autonomy of cosmetic clients, regulatory mechanisms could and should be used to improve the conditions in which women are making decisions, specifically by clarifying and distinguishing the different roles that medical practitioners may now perform and the correlative, and distinct, roles that their ‘clients’ may occupy at different times and in different contexts.

In particular, it is imperative to make clear the basis of the relationship between practitioner and client, whether it is primarily commercial in nature or therapeutic, and to prevent recruitment from one for the purpose of the other. In short, to ensure that doctors treat patients as patients and not as potential consumers of (their sideline) commercial services, and similarly to ensure that the commercial basis of discretionary medical treatments is transparent and that ‘consumers’ of such services are encouraged to evaluate ‘advice’ and expertise accordingly.

Conclusion
Patients’ ‘choices’ are inevitably limited or extended by the legal and policy frameworks that govern medical practice. One of the issues in relation to cosmetic medical practice is the extent to which it operates ‘outside’ the normal boundaries of medical practice and ‘within’ the domain of commercial exchanges and market imperatives. The argument advanced in this paper is that cosmetic ‘consumers’ will be better able to make decisions that are consistent with their values and goals and sense of self if the informational environment is significantly improved. It is suggested that this requires not only more accurate and comprehensive information about the risks of selected procedures but also clarity about the nature and basis of the doctor-client relationship so that consumers are able to assess the bias or interest of the practitioners. Decision-making behaviour in all fields is strongly guided by roles and the cues they provide as to appropriate conduct in the particular context. While the roles of (medical) patient and (commercial services) consumer remain blurred, this compromises women’s capacity to identify when ‘the doctor’ is their best advocate in ensuring that their health needs are met and when ‘the doctor’ is a commercial services provider with a vested interest in the procedures and products being considered. Quite different consumer behaviours are appropriate and warranted in each context. The capacity of the doctor to act as an independent adviser is quite different in each context. The degree of regulation in each context is quite different. Regulatory measures that make it clear to potential cosmetic clients what the basis of the relation is in the different spheres of activity and how their role changes in each sphere are one means to help ensure that women are acting autonomously when choosing to undergo cosmetic surgery.

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*Wendy Larcombe, Melbourne Law School, The University of Melbourne, Victoria 30[1]0, Australia; t: [phone]; e: [e-mail]
1 See http://au.lifestyle.yahoo.com/marie-claire/article/-/5887012/so-you-think-you-want-cosmetic-surgery/
[2] ‘Cosmetic surgery not all pretty’, Choice Online, http://www.choice.com.au/reviews-and-tests/food-and-health/beauty-and-personal-care/cosmetics/cosmetic-surgery.aspx
[3] See Adam Cresswell, ‘Call to target rogues in nip ‘n’ tuck trade’ The Australian 25 February 2009, http://www.theaustralian.com.au/news/health-science/call-to-target-nip-n-tuck-rogues/story-e6frg8y6-1111118955227 ; Brad Crouch and Evonne Barry, ‘Crackdown on cosmetic surgeries after two young women die’ Herald Sun 20 July 2008, http://www.heraldsun.com.au/news/national/crackdown-on-cosmetic-surgeries/story-e6frf7l6-1111116961794
[4] The Cosmetic Surgery Report – A Report to the NSW Minster for Health, October 1999, (Health Care Complaints Commission Committee of Inquiry) 4 http://www.hccc.nsw.gov.au/Publications/Reports/Default/default.aspx ; see also the definition used in the application of the Australasian College of Cosmetic Surgery to the Australian Medical Council: http://www.cosmeticmedicalpracticesubmission.info/
[5] The Cosmetic Surgery Report ibid.
[6] Rhian Parker, Women, Doctors and Cosmetic Surgery: Negotiating the ‘Normal’ Body (Palgrave MacMillan 2010) 21.
[7] See Ruth Fletcher, Marie Fox and Julie McCandless, ‘Legal Embodiment: Analysing the Body of Healthcare Law’ (2008) 16 Medical Law Review 321, 336.
[8] Above n 4, 10.
[9] Beauchamp and Childress as cited by Susan Dodds in Catriona MacKenzie and Natalie Stoljar (eds) Relational Autonomy: Feminist Perspectives on Autonomy, Agency and the Social Self (Oxford University Press, 2000) 215.
[10] Of course the current model of respect for patient autonomy is to be preferred over the older model of medical paternalism; the question is whether the conditions and relations in which healthcare is practised foster the richer form of autonomy described above. Informed consent can demonstrate respect for a patient’s choice but if that ‘choice’ is not ‘free’ it will not itself reflect the autonomy of the patient that is the respected value.
[11] Catriona MacKenzie and Natalie Stoljar, ‘Introduction: Autonomy Refigured’ in their edited collection Relational Autonomy, above n 9, 19.
[12] See various contributions to Relational Autonomy, above n 9.
[13] MacKenzie and Stoljar, above n 11.
[14] Linda Barclay, ‘Autonomy and the Social Self’ chapter 4 in MacKenzie and Stoljar (eds) Relational Autonomy, above n 9, 52.
[15] Ibid 55.
[16] Ibid 57.
[17] Melanie Latham, ‘The Shape of Things to Come: Feminism, Regulation and Cosmetic Surgery’ (2008) 16(3) Medical Law Review 437, 439.
[18] Above n 17.
[19] Parker, above n 6.