Abstract: !is project seeks to investigate the circumstances in which cosmetic surgery can be deemed medically 
necessary based on competing political theories of justice. !e literature review is focused on outlining various 
approaches to conceptualizing health, medical ethics, and medical necessity, and I explain the di"erences in resourcist 
and capabilitarian interpretations of medical necessity and their application to cosmetic surgery. At its conclusion, 
I hope this project advances the study of bioethics and readers contemplate implications for clinical practice, health 
care delivery, health #nancing, and health policy initiatives.

Aisthesis      Volume 13,  20221

Medical Necessity Reimagined: Cosmetic Surgery through 
the Lens of Capabilitarianism and Resourcism

by Emily Duckworth

Introduction
 !e practice of cosmetic surgery is ethically 
complicated and fraught with moral concerns. While 
there are many complicated ethical issues concerning 
cosmetic surgery, this project will investigate 
how capabilitarian and resourcist approaches to 
justice and human welfare might argue that certain 
cosmetic procedures should be considered medically 
necessary. !ese two approaches were chosen 
because they are closely related, and both attempt to 
de#ne a just society and determine how to support 
human thriving.
 !ere is a variety of literature to look at when 
considering the topic of medical necessity. In the 
review below, I draw #rst from literature concerning 
how we de#ne health, and then address standard 
approaches to medical ethics and why they are 
insu$cient when applied to cosmetic surgery. 
!e next section considers current debates about 
enhancement versus therapy and what alternatives 
to cosmetic surgery already exist. Medical necessity 
is then de#ned and related to current practices 
in the US regarding insurance coverage. Lastly, I 
outline resourcism and capabilitarianism, explain 
the di"erences in their interpretations of medical 
necessity, and discuss how these approaches can be 
applied to cosmetic surgery. 
 I will argue that medical necessity can be 
reimagined to include all services and procedures that 
individual physicians and the medical community at 
large believe to be clinically indicated for physical 
and mental health. In my larger project, I determine 

whether certain circumstances make cosmetic 
procedures medically necessary by constructing 
scenarios in which theoretical patients desire certain 
procedures. I evaluate the medical necessity of 
each procedure in these scenarios by considering 
and answering questions speci#c to both resourcist 
and capabilitarian theories of justice. By the end of 
my completed project, the reader should be able 
to develop their own framework through which 
cosmetic surgery procedures can be evaluated for 
medical necessity.

Literature Review
Health
 Much of the debate surrounding the ethics of 
cosmetic surgery is based on one’s conception of 
health. Medical practice is guided by the goal of 
maintaining optimal health; thus, health informs 
all medical decision making. !e World Health 
Organization (WHO) has de#ned health as “a state 
of complete physical, mental and social well-being 
and not merely the absence of disease or in#rmity” 
(WHO Constitution2020). !e expansive WHO 
de#nition is not fully accepted by many stakeholders, 
yet it has remained unaltered since the organization’s 
founding in 1946. As it relates to cosmetic surgery, 
the WHO de#nition appears to lend its full support 
to enabling people to feel their best via surgical 
means. However, it is unclear whether the WHO 
would truly encourage the use of cosmetic surgery to 
alleviate mental health issues and emotional distress. 
Many take issue with the inclusion of social well-



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being as a matter of health, believing it places too 
great a burden on the medical profession to solve 
social ills (Callahan 1973). Some believe the WHO 
de#nes a state of happiness, not a state of health. 
Others believe the WHO’s conception of health 
is simply aspirational since health services could 
never be e"ectively distributed and used to treat all 
potential “medical” problems that arise from this 
de#nition. Moreover, it seems quixotic to expect 
medical science to eliminate unhappiness. Critics 
cite the importance of #rst establishing physical 
health equity rather than focusing on social and 
psychological issues (Saracci 1997). Detractors of the 
WHO de#nition contend that one’s personal desire 
for cosmetic surgery represents a way for them to 
attain happiness, not health.
 Following the #rst publication of the WHO 
de#nition of health, authors have continually 
critiqued, reworked, and fashioned their own 
de#nitions, adding in quali#ers and limitations 
in an attempt to create more realistic objectives 
for medicine since many scholars have criticized 
the WHO de#nition of health as idealistic and 
unobtainable (Callahan 1973; Saracci 1997; Bircher 
2005). One such example is Johannes Bircher, who 
writes, “Health is a dynamic state of wellbeing 
characterized by a physical, mental and social 
potential, which satis#es the demands of a life 
commensurate with age, culture, and personal 
responsibility” (Bircher 2005). Bircher’s de#nition 
eliminates more recent critiques that the WHO idea 
of health cannot take into account the rise of chronic 
illness. Most physicians in the US operate under the 
idea that restoring health equates to preventing and 
managing disease with less emphasis on the patient 
as a unique individual with complex concerns and 
wants. While the WHO espouses a very holistic 
approach to health, that is far from the reality of 
American health care delivery. Physicians in the 
US spend little face-to-face time with patients and 
encounters are focused on the treatment of disease, 
management of chronic illness, and restoration of 
physical health.

Basic Medical Ethics
 One’s conception of health informs their 
application of medical ethics. Since the 1979 
publication of Beauchamp and Childress’ four 
principles of biomedical ethics, physicians have 

made medical decisions based on respect for patient 
autonomy, nonmale#cence, bene#cence, and justice. 
Respect for autonomy describes a patient’s right to 
make their own well-informed medical decisions. 
Nonmale#cence refers to a physician’s duty to do no 
harm, and bene#cence is achieved when physicians 
both improve their patient’s welfare and weigh the 
bene#ts and risks of medical intervention. !e 
principle of justice refers to the need for equal 
distribution of access, costs, risks, and bene#ts 
to patients. !ough Beauchamp and Childress’ 
principlism has long been accepted in all aspects 
of health care delivery, it has sparked much debate 
when applied to cosmetic surgery. Much of the 
literature concerning the basic ethics of cosmetic 
surgery focuses primarily on di$culties respecting 
patient autonomy and a duty to do no harm, and on 
establishing a balance between nonmale#cence and 
bene#cence (Chung et al. 2010). One way to frame 
the concerns surrounding male#cence and cosmetic 
surgery is to consider whether the procedures 
performed are considered enhancement or therapy. 
!ose who oppose widespread enhancement 
of society o%en assert that cosmetic procedures 
constitute a form of harmful enhancement and 
are thus unethical extensions of medical practice 
(Pellegrino 2004; Maio 2007).

Enhancement versus !erapy
 Cosmetic surgery has been hotly contested by 
those who view it as a complete and total departure 
from medicine, arguing that the practice caters to 
consumer-driven desires generated by a beauty-
obsessed culture. According to ethicist Edmund 
Pellegrino, cosmetic surgery constitutes “patient-
desired abuse.” Pellegrino warns about medicalizing 
all facets of society by extending the term patient to 
those who consider themselves unhappy in any way, 
whether it be with their mind, body, or soul (Pellegrino 
2004). Others argue that cosmetic surgery #ts within 
the larger framework of biomedical advancement 
and enhancement, and thus should be pursued and 
further explored in an e"ort to push humankind 
to perfection (Caplan and Elliott 2004). !e goals 
of medicine have long been focused on alleviating 
diagnostically recognized problems within the mind 
or body. With the advent and rapid proliferation of the 
cosmetic surgery industry, more traditional theorists 
take issue with what they view as an inappropriately 



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broad application of medical practice. !ose in 
Pellegrino’s camp are expressly opposed to Caplan’s 
support of extensive developments in biotechnology 
and medicine, which they worry will bastardize the 
medical profession. Maio (2007) takes Pellegrino’s 
argument further, asserting that cosmetic surgery 
cannot be classi#ed as medicine since cosmetic 
surgeons are not performing any type of “healing,” 
rather, they are acting purely on the desire of their 
patients to alter their appearance in order to #t 
in with perceived social norms. !erefore, Maio 
concludes that cosmetic surgery does not solve a 
medical problem, it only attempts to #x a social 
problem. However, in attempting to alleviate socially 
felt physical inadequacies, cosmetic surgery only 
serves to worsen that same problem by increasing 
the number of people who appear “normal” through 
arti#cial means (Maio 2007).
 In the enhancement versus therapy debate, much 
of the public remains convinced that cosmetic surgery 
is solely a method of anatomical enhancement, 
spurred on by a desire to look younger, #tter, and 
more conventionally attractive. !ere appears to 
be no consensus among theorists on whether or 
not cosmetic surgery constitutes a form of therapy 
for emotional and social su"ering related to body 
image and self-esteem. Cosmetic surgery is a gray 
area lying in between services universally regarded 
as outside the medical profession, such as tattooing 
or piercing, and procedures that are fully within 
the scope of medicine, like treating severe burns or 
cancer. Body modi#cation has a long history and 
includes a range of practices, from foot-binding 
in China to nose piercings in Hinduism. While 
cosmetic surgery is fairly accepted within American 
culture, many continue to hold negative opinions of 
those who seek out the service, considering them to 
be vain, shallow, or narcissistic (Bonell et al. 2021; 
Saxena 2013; Tam et al. 2012). !ough other forms of 
body modi#cation are now considered expressions 
of self-identity, cosmetic surgery has not been 
similarly embraced. However, scholarship devoted 
to measuring cosmetic surgery patient motivations 
has found that most patients are seeking cosmetic 
surgery in order to improve their mental, emotional, 
and social well-being. A study surveying recipients 
of cosmetic procedures found that increasing self-
con#dence, feeling happier or improving quality of 
life, and looking good professionally were common 

motives behind patients’ desires to undergo 
cosmetic surgery (Maisel et al. 2018). !ose seeking 
cosmetic surgery are not merely attempting to 
become more beautiful. Rather, through attaining 
beauty they believe they will improve their mental, 
emotional, and social health. Some theorists keep 
these motivations in mind when choosing to 
support or oppose the practice of cosmetic surgery, 
considering the profound su"ering that can result 
from dissatisfaction and unhappiness with one’s 
appearance.
 Sandman and Hansson (2020) evaluate how 
the di"erences in su"ering among those with 
“functional” and “nonfunctional” conditions should 
inform the distribution of publicly subsidized plastic 
surgery. Functional conditions are commonly 
treated with reconstructive plastic surgery and 
include trauma a%er burns or cancer. Nonfunctional 
conditions would typically be treated by cosmetic 
plastic surgery and include dissatisfaction with the 
appearance of one’s nose or breasts. Sandman and 
Hansson argue that nonfunctional conditions would 
warrant publicly subsidized plastic surgery if the 
patient experienced some form of su"ering which 
the medical system could validate, though they 
are unsure what form that validation would take. 
Additionally, the authors de#ne su"ering as a person’s 
experienced quality of life. !ere does not exist a 
clear and absolute hierarchy with regard to funding 
procedures for functional versus nonfunctional 
conditions since patients with functional conditions 
can experience less su"ering than patients with 
nonfunctional conditions. Researchers found that 
patients requesting surgery for purely aesthetic 
reasons, as compared against those with both 
functional and aesthetic reasons, scored worse 
on multiple diagnostic scales for mental health 
(Cordeiro et al. 2010). However, those requesting 
reconstructive surgery are typically prioritized in 
the health care system though they experience less 
emotional distress than those who desire cosmetic 
surgery. Sandman and Hansson argue for statistical 
normality to be used as a tool to decide what 
procedures should and should not qualify for public 
funding. With regard to nonfunctional conditions, 
statistical normality of emotional, mental, and social 
su"ering would be medically evaluated to determine 
if someone was experiencing higher levels of 
emotional distress due to their condition than what 



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was considered statistically normal. Unfortunately, 
the authors do not provide details about which 
diagnostic approaches might be used to quantify 
levels of su"ering. Additionally, the authors assert 
that physical abnormality takes precedence over 
perceived su"ering. Unlike Pellegrino’s or Caplan’s 
approaches, Sandman and Hansson do not speak 
in absolutes. Rather, they devise a strategy to help 
rationally di"erentiate between what procedures 
should and should not be considered a form of 
therapy and thus be granted public funding.

Alternatives to Surgery
 Given #nancial concerns and the scarcity of 
medical resources, when a simpler and cheaper 
treatment alternative exists for remedying an 
ailment, a physician will prescribe that method 
rather than the more costly and invasive option. 
When individuals experience mental and emotional 
struggles, they are typically encouraged to see a 
psychologist or psychiatrist to help them learn to 
cope with their feelings and progress to a state of 
acceptance and emotional stability. Unless diagnosed 
with body dysmorphic disorder (BDD), patients 
seeking cosmetic surgery are routinely granted their 
requests with little pushback from surgeons. Much of 
this phenomenon may be attributed to the fact that 
cosmetic surgery is currently regarded as medically 
unnecessary in the US, and thus, private practices 
are comfortable supplying these procedures because 
they are not covered by insurance and are paid out-
of-pocket by patients. Private practices therefore 
have no #nancial incentive to direct a paying patient 
elsewhere, even though counseling may be a cost 
e"ective and less risky treatment for their body 
image issues.

Medical Necessity
 !ough the ethical opinions surrounding 
cosmetic surgery discourse are wide-ranging, 
most authors are usually answering the question of 
whether cosmetic surgery is medically necessary. If 
the author’s response is no, their arguments adopt 
similar positions found in Pellegrino and Maio’s 
writing. If ethicists believe cosmetic surgery is 
medically necessary, they put forth arguments akin 
to those of Caplan and Sandman and Hansson.
 Scholarship on medical necessity in the United 
States focuses primarily on the vast and variable 
landscape of health insurance. Janet Dolgin (2015) 

discusses the history of the term medical necessity 
in the US and implications of the ever-evolving 
de#nitions on health care delivery. In the US today, 
individual insurance agencies determine medical 
necessity, o%en frustrating physicians who feel their 
medical experience and opinions are being ignored 
in favor of cutting costs. According to physicians, 
medical necessity refers to all actions which are 
clinically indicated. Conversely, insurance agencies 
create complex coverage plans that are o%en at odds 
with what medical professionals would prescribe 
given that they prioritize #nancial gain over the 
utilization of medical services. In 2016, the American 
Medical Association stated that medical necessity 
consists of:

Health care services or products that a prudent 
physician would provide to a patient for the 
purpose of preventing, diagnosing or treating 
an illness, injury, disease or its symptoms in a 
manner that is: (a) in accordance with generally 
accepted standards of medical practice; (b) 
clinically appropriate in terms of type, frequency, 
extent, site, and duration; and (c) not primarily 
for the economic bene#t of the health plans and 
purchasers or for the convenience of the patient, 
treating physician, or other health care provider 
(AMA 2016).

 
In 2010, a%er the passage of the A"ordable Care 
Act, the Institute of Medicine considered developing 
national guidelines for making determinations of 
medical necessity. However, this idea was never 
realized due to signi#cant pushback from private 
insurers, and medical necessity remains a variable 
and confounding principle in American health care 
delivery (Dolgin 2015). With the current boom in 
cosmetic surgery, it would be prudent to establish 
a position on the medical necessity of cosmetic 
surgery procedures. 
 !inking about medical necessity can be colored 
by social and cultural understandings of various 
procedures, such as abortion, transgender health 
care, and cosmetic surgery. Some scholars draw 
a distinction between those who receive plastic 
surgery due to a currently medically de#ned need, 
such as gender dysphoria, breast cancer, or severe 
burns, and those who desire plastic surgery because 
of personal perceptions of need or desire (Dubov and 



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Fraenkel 2018). However, individuals in both camps 
experience similar su"ering no matter the cause. 
In the same way that exposure to popular media 
has long been regarded as a potential risk factor in 
developing an eating disorder (Morris and Katzman 
2003; Spettigue and Henderson 2004), perhaps 
exposure to media may also instill in people a false 
sense of physical inadequacy that they feel can be 
recti#ed via cosmetic surgery. !e key issue at play 
is whether perceived social acceptance and personal 
psychosocial well-being are valid justi#cations for 
determination of medical necessity. While some 
believe that personal dissatisfaction is not a strong 
enough reason for requiring surgical intervention, 
others disagree.
 In the US, the idea of medical necessity has 
been conceptualized to mean whatever services 
the insurance industry believes it should cover. I 
posit that medical necessity can be reimagined to 
include all services and procedures that individual 
physicians and the medical community at large 
believe to be clinically indicated for physical and 
mental health. Additionally, though the current 
principlist approach to medical ethics reigns 
supreme, it only provides vague guidelines for 
when cosmetic surgeons should and should not 
operate. Principlism does not adequately address 
the unique complexities surrounding cosmetic 
procedures. Beauchamp and Childress’ ethical 
guidelines emphasize the importance of autonomy 
and nonmale#cence, but cosmetic surgery directly 
challenges the primacy of patient autonomy 
concerning invasive and permanent surgical 
alterations and blurs the line between harm and 
healing. When standard medical ethics are applied 
to the practice of cosmetic plastic surgery, physicians 
are le% with unanswered questions. As a result, many 
scholars have written about the ethical dilemmas 
facing the modern cosmetic surgery industry. With 
this understanding of the current ethical landscape 
surrounding cosmetic surgery, I will now pivot to 
frame those ethical concerns within the context of 
the resourcism and capabilities approaches to justice 
in order to determine how cosmetic surgery could be 
deemed medically necessary and distributed as such 
under a resourcist or capabilitarian society.

Resourcism
 !e resourcist approach to justice centers on 
the rights that individuals have to goods that will 

enable them to achieve well-being. Resourcism is a 
means-focused theory of justice, asserting that with 
fair access to goods, people can live in a just world 
no matter what they are ultimately able to transform 
those goods into. However, resourcists do not believe 
that justice demands total equality of distribution; 
some goods may be distributed unequally. !e 
resourcist approach has been de#ned by philosopher 
John Rawls’ seminal work, A !eory of Justice (1971). 
Rawls argues for justice as fairness and contends 
that when people are put in the original position 
behind a veil of ignorance, they will desire for 
all people to have an equal right to basic liberties, 
and that social and economic goods are attached 
to positions open to all and are distributed so that 
socioeconomic inequalities bene#t the worst o" in 
society (Rawls 1971). Resourcists assert that with 
fair distribution of goods, people will then be able 
to pursue their own unique goals and interests in 
society. Rawls believed that humans are su$ciently 
rational beings who, when acting on rational desires, 
can determine what is good and right for themselves. 
In summary, resourcists are primarily concerned 
with how to distribute goods in an equitable way so 
as to ultimately bring about equality or fairness of 
opportunity.
 One common critique of resourcism is that it 
does not take into account circumstances such as 
disability or prevailing social norms that impact how 
individuals are able to live their lives (Sen 1979). Some 
resourcists disagree, arguing that resourcism does 
take individual di"erences in body and mind into 
account, as well as how those di"erences in&uence 
one’s ability to convert resources into outcomes. 
One such resourcist, !omas Pogge, also explains 
that in order to address the ways in which standard 
human needs do not align with all human diversity, 
resourcists might compensate those individuals by 
giving them more resources in other aspects of life 
(Pogge 2002).

Capabilitarianism
 In response to Rawls’ distributive approach to 
justice, a new movement emerged spearheaded 
by Amartya Sen and Martha Nussbaum. Sen and 
Nussbaum articulated an alternative to Rawlsian 
resourcism, arguing instead for what they termed the 
capabilities approach. In contrast to resourcism, the 
capabilities approach is ends-focused. !e capabilities 



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approach is expressly focused on the capacity and 
capability of individuals to secure their own well-
being. Additionally, the capabilities approach 
intrinsically considers the diverse nature of human 
need across di"erent populations. Rather than asking 
what should be given to people in order for them to 
survive and &ourish, capabilitarians consider what 
people can realistically do and how they can function 
as their own change agents. Capabilities represent 
the freedoms and true opportunities people have 
to achieve di"erent states of being and doing. States 
of being and doing are thought of as an individual’s 
“functionings.” Capabilitarians remark that 
resourcism places importance on the possession of 
goods as advantageous rather than on how advantage 
is determined by the relationship between people and 
goods (Sen 1979). Within the capabilities camp, there 
is disagreement about whether these theories should 
include a comprehensive list of human capabilities 
that must be achieved. Some scholars, like Sen, elect 
not to include a list and believe each group or society 
adopting capabilitarianism should decide among 
themselves what capabilities they value. Others, most 
notably Nussbaum, fashion a fairly exhaustive list. A 
brief description of Nussbaum’s ten capabilities is as 
follows:

1. Life: Living out a life absent of premature 
death or suicide.

2. Bodily Health: !e ability to maintain good 
health via su$cient food, water, and shelter.

3. Bodily Integrity: !e ability to exist and travel 
without fear of harassment, abuse, or violence, as 
well as the ability to achieve sexual satisfaction 
and reproductive choice.

4. Senses, Imagination, and !ought: !e ability 
to use one’s senses and mind in a whole and 
meaningful way, free from infringement or 
persecution; the ability to produce creative and 
artistic works; the ability to avoid unnecessary 
pain and experience pleasure.

5. Emotions: !e ability to undergo healthy 
emotional development free from trauma, fear, 
and anxiety; the ability to form attachments and 
feel a full range of emotions towards things and 
people.

6. Practical Reason: !e ability to plan one’s own 
life according to their conception of the good.

7. A$liation: !e ability to perform social 
interactions, form relationships with others, 
identify and relate with others; the ability to 
attain the social bases of self-respect and be 
treated as equal.

8. Other Species: !e ability to feel and express 
concern for the natural world.

9. Play: !e ability to take part in and enjoy 
recreational activities.

10. Control over One’s Environment: !e ability 
to participate in the body politic, hold property 
and goods, and #nd employment, as well as being 
guaranteed freedom of speech and association 
and freedom from unwarranted search and 
seizure (Nussbaum 2013).

Regardless of di"erences within the literature, at its 
core, capabilitarianism is best summarized by the 
following statement: By serving each individual’s 
capabilities, people are enabled and encouraged to 
fully function in society.

 

Application to Health and Cosmetic Surgery
 In Rawls’ initial publication, he explicitly stated 
that health was a natural good and was granted 
through an uncontrollable lottery, and thus, it was 
outside the scope of fair distribution. Rawls’ theory 
of justice posits that only social goods should be 
distributed in order to enable individuals to realize 
and ful#ll their life plans. Rawls did however include 
freedom of the person in his basic liberties, which 
includes freedom from “psychological oppression” 
Additionally, Rawls also included a right to the social 



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Aisthesis      Volume 13,  2022

bases of self-respect and argues that this right is one 
of the most important primary goods at stake (Rawls 
1971). !e social bases of self-respect are de#ned 
by the social institutions which enable individuals 
to realize their own worth, gain the con#dence to 
pursue their life plan, and fully engage in society. 
Perhaps health could qualify as part of ful#lling the 
social bases of self-respect. As such, beauty standards 
and social expectations about appearance could be 
considered a form of psychological oppression and 
thus be protected against via plastic surgery. 
 Some resourcist scholars have pushed back 
against Rawls’ notion that individuals would not 
desire a right to health in the original position and 
have since argued that health is entirely within the 
scope of resourcist conceptions of social goods and 
rights, and that access to health care is paramount 
to a fully realized conception of justice (Daniels 
2008). Scholarly discussion about the inclusion of 
health into resourcism typically de#nes health in 
more basic terms than the WHO, focusing on social 
determinants of health that would enable normal 
functioning (Ekmekci and Arda 2015). Norman 
Daniels’ (2008) “normal functioning” approach 
is one of the most prominent examples of using 
resourcism as a theory to support the distribution of 
health. According to Rawls, all people should possess 
fair and equal opportunities for work based on their 
natal talents and skills, which is usually referred 
to as his equality of opportunity principle. Daniels 
e"ectively broadens Rawls’ original principle to 
include health care institutions as one of the players 
responsible for establishing equality of opportunity. 
Rather than add health to the list of social goods, 
Daniels maintains that opportunity is the good at 
stake. Daniels asserts that opportunities can only be 
realized when individuals experience a baseline level 
of health according to normal human functioning, 
and he thus seeks to make health a precondition of 
equality of opportunity. 
 Daniels explicitly states that his conception 
of health stands in stark contrast to the notion 
that health includes all facets of well-being and 
happiness. Rather, normal human functioning 
is based on measurable and quanti#able ranges 
of species-speci#c variation. Daniels does not 
speci#cally write about cosmetic surgery, so it is 
unclear whether he views psychosocial decline due 
to beauty and social norms as a departure from 

normal human mental functioning, whether that 
psychosocial decline meaningfully decreases one’s 
equality of opportunity, and whether society has an 
obligation to remedy reductions in opportunity due 
to psychosocial decline as it relates to beauty norms. 
However, Daniels does comment that:

!e relative moral importance of treating 
di"erent diseases and disabilities can in part 
be judged by reference to their impact on the 
range of opportunities open to us. Because this 
range of opportunities is itself socially relative, 
being a"ected by technology, education, wealth, 
and other cultural factors, judgments about the 
relative importance of treating di"erent diseases 
and disabilities will have some social variability… 
(Daniels 2000).

 
Ultimately, Daniels’ approach obligates health 
care providers to facilitate and promote the typical 
functioning of individuals in order to produce 
“normal competitors” for opportunities, rather than 
fully equal competitors.
 As noted earlier, !omas Pogge explains that 
resourcism can take into account how social 
factors and norms impact one’s ability to transform 
resources into outcomes if those di"erences are due 
to past inequalities in access to resources (Pogge 
2002). Pogge claims that resourcism can compensate 
individuals who, by virtue of human diversity, have 
been placed in a worse position in society. Pogge’s 
line of logic could then be used to argue that those 
whose mental health and body image are worse than 
others could be given special access to cosmetic 
surgery to mitigate the way societal norms have put 
them at a disadvantage.
 !e capabilities approach has also been directly 
applied to the ethics of health and health promotion. 
Jennifer Prah Ruger (2010) addresses how people 
want access to good health as well the ability to 
achieve it, and that health is a required element of 
human &ourishing as the end of justice. Within the 
capabilities approach to health, there is disagreement 
about which conception of health should be used to 
determine what capabilities are relevant to health 
status. Some believe that a full health capability 
equates to the ability to achieve all other capabilities, 
such as those included in Nussbaum’s list, while other 
theorists believe the simpler disease conception of 

7



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Aisthesis      Volume 13,  2022

health is a more straightforward method to establish 
agreed upon metrics and limits of health capability 
(Venkatapuram 2015).
 In contrast to other capabilitarian thinkers, 
Elizabeth Anderson (1999) explicitly explores how 
cosmetic surgery could play a role in a just society. 
Anderson argues that people have a right to all 
capabilities necessary to avoid interaction with 
oppressive social relationships and a right to all 
capabilities necessary to function as an equal citizen 
in a democratic state. Anderson further contends 
that functioning as an equal citizen requires one to be 
endowed with rights to the social conditions of being 
accepted by others, “such as the ability to appear in 
public without shame, and not being ascribed outcast 
status.” Anderson (1999) later hypothesizes that if 
it is too di$cult for social movements to in&uence 
more &exible beauty norms to account for the ugly, 
publicly subsidized plastic surgery could plausibly be 
awarded to those individuals. !is conception of the 
capability approach inspires many questions about 
how and whether we should di"erentiate between 
those who experience actual social discrimination 
because they do not #t in with beauty norms, versus 
those who feel ugly but who have no noticeable 
“defects” to most people.
 While most other capabilitarian thinkers do not 
comment directly on the relationship between their 
theories and cosmetic surgery, their ideas can still 
be readily applied to the practice. Under a general 
capabilitarian theory, human diversity, including 
various mental states, is taken into account. !is 
is particularly relevant to cosmetic surgery since 
two people with similar physical appearances 
may feel vastly di"erent about whether they are 
“healthy” and able to fully function in society 
as they currently exist. An individual desiring 
cosmetic surgery may experience distress such as 
embarrassment, depression, and anxiety related 
to their perceived deformity or imperfection, and 
they may feel disinclined to be social because 
they do not want to be seen around others. When 
resourcism and capabilitarianism are applied to the 
practice of cosmetic surgery, they could likely draw 
di"ering conclusions about the necessity of these 
medical procedures. !e preceding literature review 
illustrates the diverse ethical considerations that 
factor into decisions regarding the medical necessity 
of cosmetic surgery.

References

Anderson, Elizabeth S. 1999. “What Is the Point of 
Equality?” Ethics 109(2): 287-337. 

Beauchamp, Tom L., and James F. Childress. 2001. 
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