Science and Vanity

THE UNITED STATES has become a society fragmented not only by ethnicity and race but also by a multiplicity of cultural divisions of the sort that the British scientist and writer C.P. Snow once warned could destroy a society's ability to communicate. These cultural divides are especially striking in the current debate over whether to ban silicone breast implants.

On an obvious level, someone living in Southern California, where plastic surgery is common, is less likely than a northeasterner to see the subject as trivial. In a culture of audacious self-fashioning, cosmetic surgery is just another manifestation of the will to determine one's identity.

But the breast-implant debate reveals at least three other fundamental divisions -- about the interests of consumers, of women and of science -- that reflect very different sets of values and ways of understanding the world: How much justification must consumers give the government for their choices? Are women liberated by rediscovering their natural femininity or by seizing control over their biological destinies? And, at least for the sake of public policy, how do we sort evidence from anecdote?

"Vital needs" Puritans vs. pro-choice consumers: Patients generally go to cosmetic surgeons not because their health is threatened but because they want to look different. This is as true of post-mastectomy patients and burn victims as it is of women who have small breasts. Cosmetic surgery is a matter of personal desire, not medical necessity. It is elective, voluntary and usually paid for directly by the patient.

In its letter to the Food and Drug Administration requesting a ban on the implants, the advocacy group Public Citizen repeatedly emphasized the frivolous nature of cosmetic surgery: "Because approximately 80 percent of these devices have been used for breast augmentation, as opposed to reconstructive purposes, the overwhelming 'public need,' not the public health need, for these devices is the psychological benefit of having more perfect or larger breasts . . . . We do not accept that the psychological needs of women, who seek breast augmentation, are legitimate public health needs within the meaning of the {Food, Drug and Cosmetic} Act."

This failure to "accept" the desires of women to decide how to spend their own money on their own bodies puts Public Citizen clearly on the side of defining "vital needs." A self-styled consumer group, its goal is to stand in for consumers, to make choices for them.

In part, Public Citizen is simply hewing to legalistic language. But the notion that inessential products should be outlawed, even when they don't present risks, is common among many environmental activists. Disposable diapers, juice boxes and Styrofoam are frequent targets of criticism and outright bans. Greenpeace has attacked facial tissues and the Worldwatch Institute's most recent "State of the World" report calls for a national ban on throwaway beverage containers. Products from private washing machines to 747s, from toilet paper to tailored clothing, have been condemned as inessential indulgences.

Against this onslaught are arrayed the consumers who want to buy these products and the manufacturers who supply them. They try to explain what disposable diapers mean to a mother's personal freedom or why outlawing juice boxes increases trucking costs and energy consumption. And, facing the FDA, we find women who want breast implants, whether for augmentation or restoration, defending their right to choose.

Rather than having sovereignty over their bodies and bank accounts, these consumers are forced by aggressive regulators to give a "good reason" for their choices. "We have pitted one group of women against another, those who currently have a happy outcome versus those who've had an adverse outcome. I think that is a mistake," said Norman Anderson, an internist at Johns Hopkins University Hospital, on "Nightline." But Anderson, who is one of the FDA advisers who pushed for the current moratorium, was unclear on the alternative to all-or-nothing regulation; he seemed to hope that women who want breast implants would change their minds.

In the medical context, "vital needs" advocates imply that a natural but unwanted condition must be a "disease" in order to warrant intervention. Medical consumers, however, vote with their dollars and their flesh, for a contrary view: People should be able to change their bodies just because they want them to be different. And this brings us to the second great divide.

Earth Mother feminism vs. self-made-woman Feminism: The debate over breast implants is, most obviously, a debate over the role of women and their personal choices: Should women be allowed to choose unnecessary and potentially risky surgical procedures? Should a woman be allowed to alter her natural form to conform with her ideal of beauty? To make her life more convenient?

The notion that breast augmentation is simply wrong undergirds much of the hostility to the procedure. In her widely discussed book, "The Beauty Myth," Naomi Wolf characterizes breast augmentation as "sexual mutilation." And Public Citizen declares in a press release, "The widespread use of silicone gel implants for surgery that is purely cosmetic is a particularly egregious aspect of the issue."

The Earth Mother argument goes beyond breast implants, however. Consider the Pill. It is a federal crime to obtain birth-control pills without a prescription, which, of course, entails seeing a doctor. To reduce unwanted pregnancies, some women's rights advocates want to make low-dose birth-control pills available over the counter. Planned Parenthood is studying the issue.

"I don't think anybody knows how many pregnancies occur because of delayed refills, or just not getting pills on time," Felicia Stewart, a Planned Parenthood staff physician told Ms. magazine. "But it is really a lot. Anyone who works in an abortion clinic can tell you that."

Making the Pill available over the counter would empower women, giving them new control over their bodies. But it would not please the Boston Women's Health Book Collective, publishers of "Our Bodies, Ourselves," and vocal opponents of breast implants. The collective is quite hostile to the Pill because it introduces synthetic hormones into women's bodies. In its discussion of birth-control methods, "Our Bodies, Ourselves" ranks the Pill below various rhythm methods and just after abstinence.