Page 1 - Abstract
Recently, a 23-year-old male patient underwent cosmetic limb lengthening, despite the fact that his height was that of the average Indian male (5 feet 7 inches). The patient’s parents and the media criticised the orthopaedic surgeon who had performed the surgery for undertaking an unethical operation. This paper discusses the relevant clinical evidence, ethical aspects and ethical theories surrounding the case. We conclude that the surgeon’s decision to perform the surgery seems to be fair and appropriate from the ethical and clinical perspectives.

Introduction
The Ilizarov external device is usually used to lengthen a bone that is shortened due to bone loss secondary to trauma, infection, non-union of bone or congenital conditions giving rise to short bones. Recently, there was news regarding a limb lengthening surgery that was performed by a team of orthopaedic surgeons at a reputed hospital in Hyderabad (1). The procedure was controversial because it was performed on a young man whose height was 5 feet 7 inches (approximately 170.2 cm), which is considered above average for an Indian male. This case has given rise to a nationwide debate, especially among the medical fraternity, on whether this procedure was performed ethically or otherwise. The view of the newspaper itself is that the patient’s parents should have been consulted as the patient was only 23 years old.

Current clinical evidence
One paper (2) described the results of cosmetic limb lengthening among persons of normal height, while two papers (3,4) described the results in a cohort consisting of subjects both of short and normal stature. The mean height of the patients in the first paper was 170 cm. The upper limit of the range of the height of the operated patients in all papers was 174–176 cm (2–4). The total number of patients who underwent cosmetic leg lengthening was 215 (2–4). The mean age of the patients ranged from 25 to 27 years (2–4). The ring fixator type device was used for complete leg lengthening in two of the studies (3,4), while the Ilizarov device was replaced by the intramedullary nail in all subjects in one study (2). The mean height gained by lengthening of the leg ranged from 6.9 cm to 7.6 cm. The outcome reported was excellent to good in 95%–100% patients (3, 4). Ninety-four percent to 99.2% of patients were satisfied with the final outcome of the procedure (2–4). Ninety-six percent to 99.2% of patients were willing to undergo surgical leg lengthening again, despite the problems and obstacles involved, and were willing to recommend the intervention to other patients who had a subjective feeling that they were short (3,4). The incidence of re-surgery after the index procedure ranged from 12.5% to 28% (2–4). As the results of leg lengthening using the Ilizarov device have been described in the case of individuals of normal and short stature, this surgical procedure cannot be dubbed an “unusual experimental surgery”.

Principles of ethics
“Bio-ethics” refers to written and unwritten rules that medical professionals are expected to follow in accordance with professional standards considered appropriate by their peers in the same profession. Ethics is an integral part of the surgeon’s career, and every decision that surgeons make should take into account the clinical factors, non-clinical factors, ethical factors and rules laid out in the code of conduct published by the Medical Council of India. The four principles of ethics are respect for the autonomy of the patient, beneficence, non-maleficence and justice (5).

Respect for autonomy implies giving due consideration to the patient’s decision. As mature adults, patients can make their own decisions without being put under pressure by the doctor. Informed consent is obtained from patients after the risks and benefits of the procedures they are advised undergo have been explained to them completely. Choices, if available, are also explained to the patient, who then makes the choice. In a skeletally mature adult, the non-operative choice would be to have a shoe raise fitted. Doctors must take the wishes of the patient seriously. If the patient requests the doctor not to inform their parents about their condition and the plan of treatment, the doctor must respect the patient’s confidentiality and is bound not to disclose these, unless this would cause a serious health problem for the public in general. Thus, if a patient of normal stature requests a height gain surgery, the doctor cannot ethically deny this. Denying the request would mean violating the patient’s right to autonomy.

Beneficence means acting in the patient’s best interest. The doctor should be able to benefit the patient through a surgical intervention. The surgical procedure should be shown to have benefited other patients who have undergone it. Clinical studies have shown that cosmetic limb lengthening surgery not only increases the height of all patients (2–4), but also improves the person’s self-esteem (3). Denying height gain surgery to a patient who has reasonable justification for opting for the procedure would mean violating the principle of beneficence.

Non-maleficence means refraining from doing any harm to the patient. All surgical procedures are associated with some complications; however, the benefit of the intervention must be greater than the risk involved. The surgeon should not cause any harm to the patient intentionally or unintentionally. There should not be any malafide intentions in undertaking the surgical procedure. The incidence of complications of limb lengthening surgery has been reported to range from 37% to 72% (3, 4). However, most of these problems are related to soft tissue and bony parts and are of a relatively mild nature, not causing any permanent disability or handicap (3).

Justice involves the fair and appropriate allocation of resources, depending on the need. Justice also means taking a decision that would benefit not only the patient, but society as well (5). According to the principle of justice, the surgeon must exercise restraint as far as the type of surgical procedures to be performed is concerned, depending on the resources allotted. In the private healthcare system, patients pay for healthcare and hence, are in a position to choose the type of surgical procedure they wish to undergo. At present, there are no laws stating that cosmetic limb lengthening should not be undertaken in the country.

Hence, the decision to perform a surgery for height gain in patients who subjectively feel that they are of short stature is in accordance with the four basic principles of ethics. It can be argued that denying this surgery to a patient who requests it for a valid and reasonable cause would violate all four principles.