The morality of surgery for aesthetic purposes in accordance with principlist bioethics

The cult of beauty emerged in the West with the goddess Aphrodite, and reigns today in social media, driven by the worship of celebrities’ images. The “fever” of selfies fuels the desire to change. In 2013, Brazil led the world ranking of plastic surgery, overtaking the United States, according to the International Society of Aesthetic Plastic Surgery report. This excessive practice concerns the organizations responsible for medical practice, such as the Brazilian Federal Council of Medicine and the Brazilian Society of Plastic Surgery. As they have a huge impact on patients’ lives, aesthetic surgeries should preferably be carried out by specialized doctors. Patients have the right to have these surgeries and to choose their doctors; nevertheless, their autonomy is not absolute. The professional has the duty to inform the patient about the risks and contraindications of the procedure, and has the right to refuse to perform surgery if it is considered potentially harmful or hazardous to the patient’s health.

The morality of surgery for aesthetic purposes in accordance with principlist bioethics http://dx.doi.org/10.1590/1983-80422015233089 In Greco-Roman mythology, beauty arouses admiration.According to the myth, the Greek goddess Aphrodite, like Venus, her Roman counterpart, caused an uproar wherever she went, because of her unparalleled beauty.In Western culture, the heir of Greco-Roman values, women are admired for their beauty, which is considered the most valuable female attribute.Adorned and encouraged to always remain beautiful, every woman learns from childhood the importance of appearances to keep and enhance her position in society.Beauty makes her powerful and desired.
Even in childhood, and especially in adolescence, young women feel very uncomfortable with certain parts of their bodies, which (real or perceived) seems to them to not fit the expected standards.The scrutiny intensifies if the person has deformities that are congenital or resulting from trauma, injuries or cancer.Amongst youth, the nose and breasts are prime targets of this quest; however, other parts of the body and face, such as the belly, buttocks and cheekbones, do not escape harsh criticism.
As years go by, the sense of discomfort with their own imperfections tends to increase, and signs of aging, maternity marks, or "extra pounds" reinforce women's dissatisfaction with their own image, given that the ideal standard promoted by the media focuses on youth and slender bodies.These parameters instigate the quest to change aspects of one's body, feeding the vanity and the desire of women to be well accepted by society.Awakening the desire for change, in relation to what is considered disproportionate or ugly, initiates a search to alter one's form.This is the crux of the current Brazilian culture, with respect to the image of women and the expected feminine attributes.There are probably, to a greater or lesser degree, regional variations in the characteristics of what is considered beautiful or imperfect.The cult of beauty also occurs in other societies that share the same cultural roots, especially those in which the female figure is objectified and where a woman's social value is measured primarily by her appearance.

Social media, celebrities and the increase in plastic surgery
A mirror reflects our image, which is why it is has been used for centuries.It is even a key feature in fairy tales.There are those who stay for hours in front of a mirror admiring themselves, discovering details not only regarding their bodies, but primarily their face, as the face is considered the defining element of our identity.However, with current technology, the mirror is no longer the only object that reflects the body's image.
Photography came to prominence when it took part of the function that, for centuries, had been attributed to mirrors, as a result of increasingly modern devices, with cameras attached to computers and embedded in mobile phones.Together with internet access, these devices have made it possible, at any time and place, to take self-portraits and post them on social networks in real time, as in the case of selfies.
Technological advances and the globalized world enable the swift transmission of information.The internet reaches an incalculable number of users in various parts of the world in near real time.Such ease of communication contributes to virtual contact between individuals through social networks and dating websites, with diverse objectives.Some say that appearance is "a person's business card", since "first impressions are the most lasting".On social networks like Google+, Facebook and Instagram, it is common to post personal photos, especially self-portraits.Those who publish photos on these social platforms expect to present a good image and to be recognized with a "like", a "comment" and sometimes even a "share".Wikipedia defines selfie as a kind of self-portrait photography, usually taken with a handheld camera or a phone with a camera [and] was considered the international word of the year in 2013 by the Oxford English Dictionary 1 .The purpose of the selfie is to show the best angle of one's personal image for disclosure in social networks.It is the fad of the moment!A mirror of a person's self-esteem.
However, initially one might not get a good photo, entailing many attempts to get the effect one wants to project.Close-up shots, like selfies, almost always reveal deformities and imperfections, even if you use the selfie stick (monopod) to distance the camera.Due to the short distance, inadequate lighting, low resolution camera and mobile lenses, the picture usually does not match the real (or ideal) image of the person 2 .
Those who wish to look like celebrities often get frustrated, failing to pay attention to the fact that the images of the "famous" published in the media do not always correspond to reality.Before being sent to social networks, photos can undergo changes and special effects.When these effects are removed, the result is normal, not exceptional.

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The morality of surgery for aesthetic purposes in accordance with principlist bioethics http://dx.doi.org/10.1590/1983-80422015233089 According to a statement from Stephen S Park., president of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), which was published in an article on the entity's website in 2015, some people are attracted to the power, fame and attention that being a celebrity brings (...).It is important to remember that simply changing your appearance will not give you the same level of recognition.Celebrity photos are so often re-touched that their images are distorted, which can result in unrealistic expectations that propel consumers to seek excessive or extreme surgeries 3 .
The desire for recognition, fame and power intensifies the pursuit of internet users to improve their appearance, making this pursuit virtually inevitable.This gives strength to the beauty industry and consequently stimulates the growth of aesthetic plastic surgery.
Unsurprisingly there is a realization that beauty has great value in society.Vitor Ferreira, quoting Ernest Fischer says that man has always been preoccupied with the form of an object, in order to facilitate its handling, functionality and also to become visually pleasing 4 .And it is misleading to think that plastic surgery is a new technique to achieve this objective.It is one of the oldest medical specialties 5 .
The origin of plastic surgery dates back centuries before Christ, driven by the need for techniques to restore human deformities caused by trauma, physical punishments and penalties.According to historical records, these procedures started in India, where they practiced nose amputation as punishment.In modern times, the First World War represented a major milestone for plastic surgery, given the large-scale physical mutilation caused by weapons used in the fighting.In this context, Sir Harold Delf Gillies stands out in the repairing of war injuries, having been appointed as the main medical doctor who dedicated himself to the development and improvement of techniques in the reconstruction of the faces, noses and jaws of affected soldiers 6 .
Unlike the pioneering plastic surgery of the First World War, from World War II, studies and research aimed at the general population were developed, resulting in an increase in the number of reconstructive surgeries and expansion of the types of surgery, such as the ones performed in cases of fracture repairs, burns, peripheral nerves, orthopaedic corrections, etcetera 7 .
Currently, seventy years after the end of the last World War, the profile of most people who seek the procedure has changed again.Now elective surgery, focused on the improvement of physical characteristics that can be considered "normal", has taken the stage.
According to an article published in 2014 on the AAFPRS website, a survey conducted by the organization in 2013 showed an increase of requests for cosmetic procedures (especially among individuals under 30 years of age) as a consequence of the publication of selfies.The self-portrait influenced the desire for facial changes, given the perceived imperfections that respondents attributed to specific parts of their bodies.According to the survey that year there was a growth of 10% in nose plastic surgery, 7% in hair implants and 6% in eyelid surgery 8 .
In the aforementioned report, published on its website in 2015, the AAFPRS presented other research (undertaken in 2014) showing that in addition to selfies, videos also motivate the use of plastic surgery, since they reproduce moving images, thereby exposing more facial imperfections 3 .
In addition, this study, conducted with a group of 2,500 respondents who were members of the institution, found that the demand for cosmetic surgery is also motivated by the desire of people to emulate current celebrities.The survey found that 13% of facial plastic surgeons testified to an increase in requests for procedures to simulate the appearance of celebrities.In 2014, this level was well above the 3% of requests in 2013 and 7% in 2012.The most popular surgeries in 2014 were: 1) Angelina Jolie's lips and cheekbones; 2) Beyoncé's facial structure; 3) Kim Kardashian's eyes and chin; 4) Brad Pitt's nose; and 5) Natalie Portman's nose 3 .Although the study has given more emphasis to the female audience, it is worth remembering that men are gaining more and more ground in the world of beauty and plastic surgery.
What woman has not dreamed of being proposed to and presented with a diamond ring?! But, on the day, some "worry lines" have been making brides distressed!Would their hands match the beauty of the ring when the time comes to make that perfect selfie?The Brazilian Society of Plastic Surgery (SBCP) commented on a New York Times report, which warned that there was another trend in 2014 in the area of plastic surgery: the selfie of the perfect hand with the engagement ring.The SBPC informs that, according to the New York newspaper article, the finding of some surgeons is that there is, in fact, a demand from brides for wrinkle fillers, the treatment of sun marks, as well as the elimina-

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The morality of surgery for aesthetic purposes in accordance with principlist bioethics http://dx.doi.org/10.1590/1983-80422015233089tion of protruding veins, and the bony appearance of hands -all to get the perfect picture of their hand with the ring posted on social networks 9 .This confirms, therefore, the notorious influence of social networks in the cult of beauty, not to mention the impact of television and print media, especially through programs and magazines that are dedicated to disclosing the lives of the famous.
The websites of plastic surgery societies from various countries provide warnings and recommendations to the public about the harmful effects of failed interventions, seeking to prevent those who are thinking of using the procedure, inducing them to consider the risks and also informing them that the surgeries are not recommended to everyone, indiscriminately.
In general, the goal of those who resort to cosmetic surgery goes beyond the physical benefits, and relates to self-esteem, which is the reason for such warnings.Therefore, the professionals advise that people consider, as a criterion to identify the right time to look for a doctor, the moment their dissatisfaction and discomfort with their own appearance negatively influences their behaviour.In turn, these organizations consider the pursuit of resembling celebrities as a mistake, since every aspect of individual characteristics is to be respected.
Brazil has a high number of plastic surgeries.It is among the countries that most practice this type of procedure.According to SBCP, the 2013 report from the International Society of Aesthetic Plastic Surgery (ISAPS), mentions Brazil as foremost in performing cosmetic surgery, overtaking the United States 10 .The desire to achieve ideal beauty through the tip of a scalpel is increasingly common in the country, including individuals of various ages and socioeconomic groups.Because of its high cost and because it is not considered an essential service guaranteed by the Brazilian Public Health System (except for remedial interventions in specific cases), surgery for purely aesthetic purposes ends up being one of the targets in the commercialization of medicine.
In the case of plastic surgery and other similar cosmetic procedures, this commercialization has spread in Brazilian society, to the point where these services are offered through leaflets, billboards, newspapers, magazines and electronic media, with the marketing of beauty treatment "plans", that is predefined sales with certain values, even before the assessment of the patient by a doctor.This state of affairs led the Procon-SP Foundation, an agency of the Department of Defense and Citizenship of the State of São Paulo, to request a ruling from the SBPC 11 .In response, the organization decided to stimulate discussion in the medical field, resulting in the issue of Resolution 1,836/2008 of the CFM in order to discipline the financing plans or rotating savings and credit associations (ROSCA) for medical procedures, including those for aesthetic purposes 11 .According to an article published in CFM's website 'Portal Médico' , a survey of the Brazilian Association of ROSCA Administrators (ABAC) held in 2012 showed that in the first half of that year, interest in ROSCA that focus on services had an increase of over 25% and that the specialty "health and beauty" led the ranking amongst these ROSCA, with nearly 16% of the letters of credit.Also according to the article, SBCP considered these figures with concern 12 .
Teenagers also turn to doctors' offices in search of aesthetic results.According to a post from Diego Cordeiro published on the official SBCP blog, the discussion about the real needs of these adolescents to undergo cosmetic surgery is growing in line with the growth of demand for these surgeries.Although many professionals consider that people of this age group should not submit themselves to such procedures, the number of plastic surgeries for adolescents and young people grew 141% between 2008 and 2012.Cordeiro said that about 60% of plastic surgery undergone by teenagers are aesthetic, and, among them, liposuction stands out as one of the most sought after procedures 13 .In other words, the desire to change appearance is not only among the older generations.
According to SBCP, the ISAPS report confirms this high demand for liposuction 10 .The CFM, through Resolution 1711/2003, stipulates that this type of surgery should not be indicated for weight loss purposes (article 2), restricting the use of these procedure to the correction of body contours in relation to the distribution of subcutaneous adipose tissue (article 1).The doctor who executes the procedure must have specific training, and a prior qualification in general surgery is mandatory (article 3) 14 .Therefore, to perform a liposuction, rhinoplasty, mammoplasty, blepharoplasty or any other surgery, appropriate medical training is essential, in order to provide security for the patient and society.
In addition to these technical, procedural and structural aspects, it is important that the patient be alerted about the need to be in harmony with their inner and outer beauty, to have a better understanding of their physical characteristics and to

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The morality of surgery for aesthetic purposes in accordance with principlist bioethics http://dx.doi.org/10.1590/1983-80422015233089reflect on their real wants and needs.It is essential to know one's own body, its limits, and maintain self-esteem.The doctor has a duty to their patients to clarify these matters, as well as to inform them about the diagnostic and therapeutic procedures to be adopted.

Doctor-patient relationship and bioethics
The aesthetic plastic surgeon handles a wide range of concepts and standards of beauty, imposed daily by the media, by celebrities, etcetera, which incite the desire of the patient to achieve the "perfect" image.This fact has turned into a new challenge for the physician, whatever their speciality, that is, to understand the perception that the patients have of themselves, how they see their body and face, as well as the psychological effects of this projection.Such understanding is essential, since the patient is looking for results that meet not only the real goal, but also one that is pictured in their own mind -the intangible.
In this sense, the knowledge of the standard or reference of beauty defined by society can work as a guideline for professionals in their attempt to understand the patient and their motivations.Proof of this is the increasing desire of people to replicate, in themselves, the facial features of artists and media icons.However, the physician must be aware of the fact that the face of each person is unique, and that there is no way to impose the same ideal of beauty on everyone, for this singular appearance is a trace of individuality and, therefore, changes from person to person.However, as we live in an increasingly 'mass appeal' society, people end up taking on these standards as examples to be pursued in order to respond to the hegemonic concept of beauty.
The medical practice of plastic surgeons alters the physical characteristics of their patients, so it requires the relationship between them to be profound and humane.As the impact of changes in appearance goes beyond the physical level, the physician must be sensitive to understand the expectations and limits of their patients.What might be perfect for some, can represent great dissatisfaction for others.Consequently, practitioners have to commit to acquiring technical expertise and pursuing scientific innovations without neglecting respect for the patient and other intersubjective aspects that guide good relationships; only in this way can they play their role with humility and for the greater good 5 .
Among the propositions defended by principialist bioethics, the principle of autonomy, also known as the principle of respect for the individual, stands out 15 .This provision relates to the need to inform the patient -clearly and precisely -about all the procedures to which they will be subjected, as well as ensuring the absence of any pressure in order to obtain the patient's acceptance or rejection of the proposed treatment.According to the principialist theory Tom Beauchamp and James Childress explained in "Biomedical Ethics Principles" 16 , it is essential to maintain these parameters, so that the person can express their consent (or not) to submit to any medical act.One can consider this principle as a moral rule, supported by many deontological professional codes, which allow very few exceptions to the principle of autonomy, especially in cases of imminent risk of death.
In accordance with Articles 22 and 31 of the Code of Medical Ethics (CEM) 17 , the informed consent form is a document containing the necessary clarifications about the objectives and rationale of the procedures to which they will be subjected.It informs patients of the discomforts, potential risks and expected benefits, alternative methods of diagnosis or treatment, side effects and specific complications.Such a document is mandatory and the form is written clearly to detail accountability of predictable failures and should apply irrespective of the magnitude of intervention 18 .The informed consent document is the right means for the patient to express their will and to become aware of what can and will happen during a procedure or surgery.
To be valid, the document must have the free and spontaneous consent of the patient.The patient must fill and sign the form, in order to certify their competence and ability to understand and consent to its contents.Moreover, it has to be backed up by verbal information that is sufficient, clear and appropriate, so that the patient can understand the information in its entirety 18 .According to Teresa Ancona Lopez, the duty to inform is one of the duties attached to objective good faith.Thus, the general rule of good faith must be present at all times in the doctor-client relationship from both sides 19 .
The doctor-patient relationship is relevant to the development of a successful medical practice, especially when it comes to surgery for aesthetic purposes, in which the patient is seeking to improve their appearance, and all possible risks must be brought to their attention.The existence of physical harm, or results that differ from what was expected, can cause numerous consequences to the patient's

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The morality of surgery for aesthetic purposes in accordance with principlist bioethics http://dx.doi.org/10.1590/1983-80422015233089life, including those of a psychological nature.Therefore, to achieve the desired result, it is extremely important that the doctor-patient relationship be based on trust and transparency.
A healthy person who undergoes cosmetic surgery has a specific goal: to improve their appearance.Due to this circumstance, the responsibility of the physician to the patient increases, and the patient must be informed -preferably personally and explicitly -of all the risks and rewards inherent in the procedure.In this case, the duty to inform is more imperative than in the case of surgery without aesthetic purposes, especially because, if the doctor does not inform the patient properly, the doctor will answer for an obligation of results 20 .
However, it should be noted that, both in this and in other cases, the physician has full autonomy to refuse to perform the procedures.Doctors should not perform surgeries when they are convinced that such intervention can bring more harm than good to the patient.Therefore, the patient's autonomy and their right to choose are limited by the autonomy and responsibility of the professional.Whenever, in the physician's understanding, the patient's wishes pose a risk to their own physical and mental health, the doctor should refuse to treat them, even if such conduct is infringing the patient's autonomy.This refusal is provided for in the principialist theory, which takes into account the prima facie principle 21 .

Plastic surgery, legislation and CFM resolutions
Certainly, there is nothing wrong with wanting to improve one's appearance and seeking the desired results.And aesthetic plastic surgery is a means to achieve that purpose, resulting in benefits to the patient's physical health, and psychological and social wellbeing.According to Article 1 of the CFM Resolution 1,621/2001, plastic surgery is a unique, indivisible specialty and as such should be performed by qualified doctors, using standard and scientifically recognized techniques 22 .
However, it is necessary to avoid excesses and negative complications during surgery or procedures.Therefore, it is important that the patient knows the professional to whom they entrust their body, health and life.The training and experience of these professionals are critical to achieving a positive surgical outcome.
According to article 17 of Law 3,268/1957 in force in the country 23 , a doctor with a diploma registered with the Brazilian Regional Council of Medicine (CRM) can work in any field, even without a specialist title.As a result, CFM could not create a resolution making it compulsory for plastic surgeries to be conducted only by physicians specialised in such practice.However, this situation can change with the regulation of the legislative powers of CFM, as prescribed in Article 7 of Law 12,842/2013, also called the Medical Act Law 24 .
In the US, for example, qualifying as a plastic surgeon can occur in two ways.The first, by a combined program, in which the candidate undertakes a single selective test, having just completed training in medicine.A resident doctor will then do three years of general surgery and two or three years of plastic surgery.The professional may still need one more additional year of research between their residency in general surgery and plastic surgery.Another means of training future US plastic surgeons comes from the traditional program, for which it is necessary to pass two selective tests, one for admission to the general surgery program, lasting five years, and another to enter the plastic surgery program, which lasts two to three years 25 .
As mentioned before, in Brazil, there is no legal requirement for a specialist qualification in plastic surgery to perform the procedure.Article 20 of the current legislation 23 provides only that, to promote operations in any medical field or specialty, the professional must be registered with the CRM.Regarding the plastic surgery speciality, the resolutions of CFM recommend that, to perform the procedure, the physician should have specific training, including a mandatory prior qualification in general surgery, among other recommendations and determinations defined in related resolutions.
However, what was mentioned earlier must be emphasized: that Article 7 of Law 12,842/2013 was introduced to enforce the supervisory powers of the CRM and CFM, covering the inspection and control of procedures of an experimental nature when these do not meet certain requirements under this same law 24 .In this context, the CFM is expressly authorized to issue regulations on medical procedures, and may even consent to these procedures by requiring that the physician have a certain degree of technical knowledge, or prohibit professionals who do not possess a specialist title from practicing these medical procedures.It is noteworthy that the recent Decree 8,516/2015, regulates the formation of the National Specialist Register, with a view to assisting

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The morality of surgery for aesthetic purposes in accordance with principlist bioethics http://dx.doi.org/10.1590/1983-80422015233089 the ministries of Health and Education as a source of information for the regulation of public health and health education 26 .
The register will have official information regarding the medical speciality of each medical professional contained in the databases of the National Medical Residency Commission (CNRM), the CFM, the Brazilian Medical Association (AMA), and the associations of different specialties related to these organizations.Decree 8516/2015 also establishes a Specialties Joint Committee under the CFM, giving it the power to define, by consensus, the medical specialities of the country, while the CNRM determines the competence matrix for the training of specialists in their field of medical residency 26 .
Despite the practice of plastic surgery being made available to all professionals registered at the CRM, in 2001, CFM considered such a procedure as a medical speciality.Since then, the practice has come to be regulated by the organisation, and the professional is recognized once they register a specialist degree, which must have been obtained on completion of a medical residency accredited by the CNRM, or upon passing a specific test applied by SBCP.To enable professionals to declare themselves plastic surgeons, CFM defines a number of prerequisites as well as technical and scientific knowledge acquired during college or postgraduate studies (medical residency and/or specialisation) 22 .We reiterate that, in accordance with Article 4 of Resolution 1634 CFM/2002, the doctor may only declare links with a speciality or field of expertise when possessing a corresponding degree or certificate, duly registered with the Brazilian Regional Council of Medicine 27 .
As stated in this same resolution, the three entities -CFM, AMB and CNRM -signed an agreement that assumed common behaviours in the adoption of new medical specialties in Brazil.The agreement states that three years of training are necessary for professionals to register themselves with the CNRM and AMB as specialists in plastic surgery, provided they have passed, as has been mentioned before, a medical residency program in plastic surgery or an exam conducted by SBCP 27 .Normally, the title of specialist in plastic surgery is preceded by a residency in general surgery, with an average duration of two years, which follows the six years of graduation.It is clear that, adding up all this time, the qualification of a plastic surgeon is the result of at least 11 years of study.
With support of Article 17 of Law 3268/1957 23 , doctors without proper expertise have also been per-forming plastic surgery for aesthetic purposes.Many of these surgical procedures are extremely complex and, when the results are negative, often catastrophic, and can lead to the death of the patient.Another reason for the CFM and SBCP insisting on plastic surgeons having academic qualifications, is both for the protection of patients and for the protection of the medical profession itself.
As a regulatory body of professional practice, CFM adopted the "Manual of administrative procedures" to guide the supervision of doctors' registration numbers with CRM and to establish criteria for the operating permit of medical services of any nature 28 .This manual also stipulated the minimum criteria for the operation of establishments in which plastic surgery can be performed, and prohibits those that do not meet these requirements, based on the manual for medical auditing and inspection in Brazil 29,30 .It is noted, therefore, that the rules of CFM are not limited to the medical act, because they also apply to medical environments and services, thereby ensuring adequate conditions for their practice.
These guides are intended to ensure safe medical care for the population.Based on this imperative, CFM considered three basic conditions for carrying out such procedures: 1) adequate physical environment and building; 2) equipment and supplies for the workup, therapeutic application and rehabilitation procedures, as well as investigative diagnostic methods; 3) infrastructure to treat complications of interventions, if applicable 29 .
The CFM determinations are of paramount importance in light of the significant increase in aesthetic plastic surgery in the country.According to CFM, medicine cannot be practiced for the purpose of commerce, advertising with images and patient outcomes cannot infringe ethical principles, and the responsibility of the doctor during care of patients is integral, unique and non-transferable, both in the diagnosis of disease and deformities, and in the indication and undertaking of treatment.
Taking into account the responsibility of the physician, CFM, through Resolution 1836/2008, stated it was necessary to prohibit the medical care of patients referred by companies that advertise and / or market financing plans or ROSCA for medical procedures 11 .According to the regulation, it is up to the professional to set values and the method to charge their fees, by referring to the CEM.

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The morality of surgery for aesthetic purposes in accordance with principlist bioethics http://dx.doi.org/10.1590/1983-80422015233089

Doctor's responsibility
Hippocrates, quoted by Beauchamp and Childress, advocated that the doctor should have at least two objectives: help or, at least, do no harm 31 .Such teaching corresponds to the principle of non-maleficence (do no harm to the patient), present in the medical code of ethics worldwide and reproduced in the principialist theory.In addition to this, there is another Hippocratic precept that guides both medical practice and principlism: the principle of beneficence, which is to do good for the patient, I will apply all measures for the benefit of the sick according to my power and understanding, never to cause damage or to harm someone (...) In every house, I will come for the benefit of patients, keeping myself far from all voluntary damage 32 .
In medical practice, however, it is humanly impossible not to have errors, failures that cause harm to patients, and can in some cases be attributed to physicians and, in other cases, to the technical problems of hospitals, not to mention other plausible hypotheses.In the medical field, generally, one does not work with guaranteed results, because the doctor has the obligation of means, not of results.However, in the case of plastic surgery for aesthetic purposes, it is assumed that the obligation is of results, as ruled by the Brazilian Supreme Court in 2013 33 , although the doctor's responsibility, even in case of purely cosmetic surgery, remains subjective and is established upon proof of guilt.
The obligation of the doctor to repair the damage caused to the patient is dependent upon such evidence, since the sole paragraph of Article 1, Chapter III, of the CEM states that medical responsibility is always personal and cannot be presumed 17 .Therefore, patients who complain of malpractice must prove such a claim; otherwise, the doctor cannot be held responsible.This is because, the Brazilian legal system, does not adopt the premise of professional risk 34 .
The application of consumerist responsibility to the doctor-patient relationship suffers from contradictions.However, one must keep in mind that this relationship is far from being a mere product, especially because it is founded on the essential care of the patients' health.There is no need to ignore its application when it comes to health facilities, which hold strict liability.Notwithstanding the provisions of paragraph 4 of Article 14 of the Brazilian Consumer Protection Code, according to which the personal responsibility of independent professionals shall be determined upon verification of guilt 35 , the doctor develops a very personal involvement, which has a contractual nature, even if it is verbal or tacit.
According to the Civil Code, the offender will be required to indemnify the victim or the victim's family in the case of murder (article 948), by injury or other harm to health (article 949), including if this injury or defect prevents the victim from working, exercising their profession, their trade, or decreases their ability to do so (article 950).The offender must also bear all the costs of lost earnings and treatment, compensating for any pecuniary loss that the victim might incur as a result of licit action taken by the offender, when this, by negligence, recklessness or professional malpractice, causes the death of patients, aggravates their illness, causes them injury, or makes them unable to work (article 951) 36 .
In addition to being subject to the ethical (CEM) and civil (Civil Code) responsibilities, doctors are also criminally liable if they practice any conduct specified in the Penal Code, such as illegally practicing medicine (article 282), issuing false certificates (article 302), omitting to give notification of reportable diseases (article 269), and violating professional confidentiality (article 154), etcetera. 37.
CRM and CFM seek to curb the practice of an offense, investigating complaints in order to determine the responsibility of the physician at fault and applying the appropriate penalties when guilt is proven 23 .The medical error occurs when the professional -acts with incompetence, recklessness or negligence in the practice of medicine -performs conduct in violation of procedures, or of the rules and legislation aimed at regulating their actions and preventing such a mistake, resulting in damage to the life or health of the patient.In addition to safeguarding the profession, working ethically and respecting the life and dignity of human beings, doctors must do everything in their power (diagnosis and treatment) for the benefit of patients, without harming them.
Research conducted in the CFM Ethical-Professional Process System 38 , on the 23th March 2015, showed that, among the specialties that most infringed Article 1 of the CEM, which prohibits doctors from causing harm to patients, by act or omission 17 , plastic surgery was ranked third.It is noteworthy that the statistics do not necessarily correspond to mistakes made by experts from the fields indicated, but to the specialities with more ethical infringements, whether the physician was an expert or not.Aesthetic damage occurs as a result of an unwanted and vex-

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The morality of surgery for aesthetic purposes in accordance with principlist bioethics http://dx.doi.org/10.1590/1983-80422015233089atious change in the patient's body 39 , affecting the patient both physically and mentally, besides exposing them to embarrassment and humiliation in the social sphere.These statistics corroborate the need to impose limits on the exercise of medical practice in general.Such an imposition is not intended to suppress good people, but to indicate ways to prevent errors and promote patient safety.

Final considerations
The promising market that plastic surgery has become, mainly for aesthetic purposes, does not preclude physicians' ethical duty to treat medicine as an essential activity for human life.To exercise it, the professional as well as being conscientious, competent and qualified, must ensure, for the greater good, the life and well-being of their patients.
The mechanisms that influence the growing demand for cosmetic surgeries revolve around the exacerbated spread of unequivocal standards of beauty, based on slimness and a youthful body and face.Electronic media, through selfies and postings on social networks, as well as news stories published by other means, lead fans and celebrity admirers to seek these, sometimes unrealistic, standards of beauty.Physicians should make their patients aware as to whether or not these procedures should be applied.
Clinical bioethics, especially its principialist aspect, cherishes the best doctor-patient relationship.In medical practice, therefore, the principles of beneficence, non-maleficence, autonomy and justice propounded by principialist bioethics should be practiced daily, so that neither the patient nor the doctor are subjected to unethical and harmful situations.The doctor has a duty to do good for each patient, without harming them; the doctor's conduct should be guided by ethics, be appropriate and fair, resulting in providing correct, accurate and instructive information to their patients in order to ensure they enjoy their freedom and autonomy to make decisions.By contrast, doctors have their rights, including the right to refuse medical or surgical procedures that go against their values, knowledge and experience; that is, the right to refuse to perform interventions that they consider unethical and that can be more harmful than beneficial for the patient.
One of the main functions of organisations that regulate, inspect and control the practice of medicine -CFM, CRM, AMB, SBCP -is to safeguard the technical and legal performance of medicine, by demanding more specialized training, defining ethical and procedural criteria, avoiding harmful acts, and investigating and punishing possible and potential medical errors.In view of this statute, it is of paramount importance that these institutions devote themselves to the fullest, to impose limits on cosmetic surgery whenever there is a hazardous situation for the patient, which will inevitably impact on the medical field itself.

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Statistics of medical areas with more notes for infringement of Article 1 of the Code of Medical Ethics -This statistic is compiled based on professionals reported, since an infringement process can have more than one professional reported.Survey of the penalty for infringement of letters "a", "b", "c" and "e" of Article 22 of Law 3,268/1957.