This week one of the local news networks called me to ask about the ethical issues of Michael Jackson’s ventures with cosmetic surgery – from the surgery to his facial bones to the depigmentation of his skin due to vitiligo. I immediately remembered the plight of a little boy with raised ears and how, when a child in the United States, he was call ‘Big Ears’. Even when locally he went to hospital to have them corrected, he noticed how the medical community was not very reassuring in labelling his condition as ‘Bat Ears’. Yet in Malta he was never the subject of teasing, although his childhood experience rendered him the habit of covering his ears with his hair. The surgery brought about a dramatic change in personality. The cause of his plight – social pressure.

There are many bodily conditions which render people dysfunctional in today’s society. Some of these conditions can be very distressful; others depend a lot on personality and indeed what is fashionable. A person with a large lip would certainly qualify for a cosmetic correction. So would the above child with bat ears. But the latter, as the experience shows, is more of a condition in which society, or the society which he had been in before, had put in the ‘scar’.

I once had a discussion on whether cosmetic procedures should be put on our National Health Services. Of course we pay for every surgery with our taxes, and when it comes to cosmetic surgery such as breast reduction or breast enlargement, we may say that we are at the limit of what is justifiable to pay for with our taxes. Yet we can come to understand that a woman may indeed suffer if she has breasts which are too small or too big. While all would wish to fit into a comfortable C-cup, those who have no cup at all or those who go into the triple E (forgive my ignorance of sizes) will have a right to feel uncomfortable.

But what is it they feel uncomfortable about? Are we creating stereotypes, the adherence to which, leads to severe psychosocial disablement? Certainly there are medical reasons for much of the cosmetic surgery that takes place – from varicose veins to breast reduction and even bat ears – which render the person somewhat acoustically challenged insofar as anatomical structure is concerned (although not so much physiologically). But it is a more psychological reason which these people seek by the procedure.

There are certainly cosmetic procedures which have controversy around them, such as circumcision, which are done more for cultural reasons, both in males and females, than for anything else. When it comes to obesity, we may all agree that liposuction and removal of extra body fat may not fall within the realm of tax money, although a gastric reduction for those whose weight is endangering their lives, will certainly find such sponsorship. The point being that there is a very fine line in defining health issues. Health, pathologically speaking, is the absence of disease. But this definition falls short of the psychosocial definition of health, which affects people differently. It would have to be broadened to include psychological health. But drawing a line here would be of course subjective.

So what message do we get when a celebrity like Michael Jackson is renowned for his cosmetic procedures, from cosmetic skin manipulation to changes to his chin, cheek bones and four rhinoplasties? After all, many women celebrities continuously undergo cosmetic surgeries. Allegedly his wish was to look more masculine (when he had his chin prosthesis) and the skin depigmentation was due to a skin condition called vitiligo, in which areas of the skin become depigmented. He therefore tried to make further depigmentation in order to bring his skin more uniform, but his critics never left him alone for this, saying that in effect he wished his skin to be lighter.

Being a celebrity, one can forgive him with the rest of them, for the vanities which we cannot always afford. Let us, for argument’s sake, assume that there was an ulterior intention to depigmentise his skin other than his medical condition. Prima facie one would certainly be unforgiving for a member of the black community, who suffered so much due to the colour of his skin. I have just finished reading Obama’s Memories from my father, which not only does justice to its author for its narrative and authorship, but equally to the lingering discrimination which the black community continue to experience. Certainly Michael Jackson was not one to suffer for his skin colour. Or did he? Why would he undertake so painful a process, which it seems rendered him immunodeficient for long periods, and probably contributed towards his death. A medical condition would not have affected his career, but we can perhaps forgive him since he was a celebrity. However the choice to lighten the skin was certain to send some resounding messages amongst some members of the black community. Certainly, make-up would probably have made up for it.

There is no doubt that everyone has a right to decide what cosmetic procedures to undergo on his or her own body. Others can be quite controversial. One of my law students brought a case where the American parent of a Japanese girl wanted cosmetic surgery on her eyelids, because they close when she smiled. Evidently however many Japanese people carry out these procedures on their eyelids in order to look more ‘Western’. The case was illuminating in its cultural aspect and how people may feel that their culture and their looks may be inferior to others.

Western culture has had a negative impact on many peoples. From skin colour to other racial characteristics. Not only, it seems that western people themselves have created icons of the ideal body image causing enough distress for some people to seek the surgical blade. But trends also change. There was a time when a voluptuous breast was the in-thing. More recently, smallish breasts were trendier and those with the larger breasts felt that they could not buy all the fashion. I have heard that the trend is shifting yet again.

Can we treat the body like we treat our fashions? Should doctors accede to such wishes? I think that within limits we can support people on national health schemes, especially for conditions which affect the well-being of an individual. Sometimes this well-being is more difficult to support and many will have to resort to private means. The doctor is still within ethical grounds to accede to such wishes. It is questionable whether doctors should accede to the changing of one’s skin colour. Certainly racial issues have caused a lot of pain – but the cure lies in education of those who induce the pain. If all black people had to change the colour of their skin, it would indeed be a tragic image of what humans can make each other do.

Some people undergo cosmetic surgery because of their jobs. If they pay for having fuller lips, or removing wrinkles, this may be fine. To pay for a change in skin colour is accepting a radical change in identity. Not only, as a celebrity, someone like Mr Jackson, may be giving the wrong message to people like him. I am not sure whether towards the end of his life he was still justifying his reasons. I am more certain that it did not earn him more money, celebrity, and certainly more respect. It just makes me feel bad, as a white person, if a black person had to feel so bad about his skin colour. But mind, the fault does not lie with Mr Jackson, for if someone like him can afford it, what about those others who would have if they had the means? It certainly would have spoken volumes about how people hurt each other. What if we come to the point, certainly not so far off, of having a gene manipulation that can alter the genetic predisposition to be black? Then one may not need the money that Michael Jackson had, and indeed someone like him may easily have served as a role model.

It simply goes to show that much of what we consider ethical in nature is as much a social issue as it is truly medical. It becomes medical by affecting our psychological perception. Young single mothers today accept much of what previously were unwanted pregnancies, because the social perception (and acceptance) has changed. If people accept me for who I am, then maybe I will not need to change the colour of my skin and indeed be proud to carry it. If people accept the old man who takes more time to climb onto the bus than the busy world around him would have, then maybe we can all even grow old with more dignity and joy, and not seek some ‘cure’ for a condition which we come to call ‘aging’.

Health is indeed the absence of Pathology.

But how much of this pathology is often man-induced? We cannot blame the person who changes the colour of his skin. Not because it was Michael Jackson, whom many of us loved for his music, and who amply made up for his eccentricities by the numerous charities he set up for children, but because it was the society around him which made him do that. We simply have to assume that something like that could have happened to someone who would use a medical excuse used only as a cover-up.

If girls in Japan want to change their eyelids, people who are discriminated against because of their skin colour may resort to such a method if it becomes genetically and financially feasible. He may have been eccentric in many ways, but writing his dermatological ‘treatment’ down to eccentricity would not do justice to ethical discourse. The ethics, as often is the case, does not lie merely in the manifest agenda (that of skin colour), but in the many facets of non-manifest agendas that rule our lives, one of which is prejudice. Those who accuse any form of act, from changing the colour of one’s skin to abortion, should not only question the act but question what brings these acts about.

Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of Family Doctors.