Volume 3, Issue 2 Should We Prohibit Breast Implants 37 Should we prohibit breast implants? Collective moral obligations in the context of harmful and discriminatory social norms JeSSiCa Laimann University of Bristol aBSTRaCT in liberal moral theory, interfering with someone's deliberate engagement in a self-harming practice in order to promote their own good is often considered wrongfully paternalistic. But what if self-harming decisions are the product of an oppressive social context that imposes harmful norms on certain individuals, such as, arguably, in the case of cosmetic breast surgery? Clare Chambers suggests that such scenarios can mandate state interference in the form of prohibition. i argue that, unlike conventional measures, Chambers' proposal recognises that harmful, discriminatory norms entail a twofold collective moral obligation: to eliminate the harmful norm in the long run, but also to address unjust harm that is inflicted in the meantime. i show that these two obligations tend to pull in opposite directions, thus generating a serious tension in Chambers' proposal which eventually leads to an undue compromising of the second obligation in favour of the first. Based on this discussion, i develop an alternative proposal which, instead of prohibiting breast implant surgery, offers compensation for the disadvantages suffered by individuals who decide not to have surgery. Journal of Practical Ethics JESSICA LAIMANN38 1. inTRODUCTiOn Liberal moral theory generally considers paternalistic interventions, that is, interventions with an individual's choice that are justified exclusively in terms of the individual's own good, as prima facie morally wrong. Call this the non-intervention rule. The presumption behind the non-intervention rule is that we ought to respect the individual's autonomy-unless we have reason to think that someone's self-harming behaviour is not the result of that individual's autonomous choice, for instance because of psychological or cognitive impairments that undermine some minimal requirements of rationality, we ought not to interfere with their decision in order to promote their own good. Clare Chambers does not object to the general liberal stand against paternalism. However, she argues that some self-harming choices do permit state intervention. These are choices made in the context of discriminatory and harmful social norms (see Chambers 2008). Such norms typically require individuals to inflict some form of harm on themselves in order to attain socially regulated benefits or to avoid socially regulated disadvantages. importantly, harmful social norms are characterised by the fact that the link between the self-harming behaviour and the regulated benefits is a purely social one-engaging in the harmful practice makes it easier or more likely for the individual to attain the benefit primarily or only in virtue of the existence of certain social conventions, values, or attitudes. Hence, athletes who decide to undergo a harmful training routine in order to break a personal record are not victims of a harmful social norm. Their engagement in harmfully intensive training allows them to break their personal record independently of surrounding social values or attitudes. Sometimes the harm-conditionality of socially regulated benefits applies only to some groups in society but not others. Hence, while some individuals need to engage in self-harming behaviour in order to attain certain benefits, others can attain comparable benefits 'for free', without having to pay the costs of self-harm. in such cases, the relevant norm is both harmful and discriminatory, thus undermining social or political equality. Chambers suggests that such norms are particularly problematic if they feed into existing inequalities, such as those related to gender or race. Volume 3, Issue 2 Should We Prohibit Breast Implants 39 according to Chambers, the practice of cosmetic breast implant surgery is motivated by such a harmful and discriminatory social norm. The relevant norm requires that women have breasts of a certain shape and size in order to be socially valued and respected (in virtue of being considered sufficiently beautiful or sexually attractive) and to succeed in a number of career paths, such as being an actress, or a model, or simply to "become famous" (see Chambers 2008, 197-198). as a result, the norm disadvantages women who do not conform in psychological, professional, or economic respects. Chambers argues that the underlying norm only affects women, hence is discriminatory. it is also harmful, in several different ways. Chambers focusses on physical harm and status harm. Breast implants, Chambers explains, involve painful and medically unnecessary surgery which likely requires lifelong further operations and poses serious long-term health risks (e.g. in the form of implant rupture or capsular contracture). in addition, she argues, having breast implants inflicts status harm on women because it casts them as objects of male sexual desire, hence as inferior to men (see Chambers 2008, 186-190). Finally, breast implant surgery and the further medical treatments which are likely to occur require substantial financial investments and thus impose economic harm in addition to physical and status harm. against this background, Chambers defends prohibition of breast implants both as a legitimate and, at least in principle, effective means of addressing the underlying harmful and discriminatory social norm. importantly, her proposal aims to prosecute not women who seek breast implants, but individuals and companies who provide it, such as surgeons or manufacturers of implants (Chambers, 2008, 217). i believe prohibition provides the wrong solution to an accurately diagnosed problem. For this purpose, i first identify a crucial strength of Chambers' proposal. Unlike conventional measures, such as education campaigns and media regulations, it recognised that the existence of discriminatory, harmful norms poses a twofold moral obligation-not only to eliminate the norm in the long run, but also to address the ongoing infliction of unjust harms while it remains in place (Section 2). Second, i discuss Chambers' defence of prohibition in more detail (Section 3). i argue that Chambers' defence against paternalism fails (Section 3.1), and that prohibition's credentials with regard to promoting gender equality, and providing respect for women are more mixed than she admits (Sections 3.2 and 3.3). i then discuss how these problems reflect a tension between the different requirements entailed by the first and the second moral obligation, and conclude that prohibition ought to be rejected for unduly compromising the second moral obligation in favour of the first. Drawing on Journal of Practical Ethics JESSICA LAIMANN40 these insights, i develop an alternative proposal that combines conventional measures, requirements for informed medical consent, and compensation payments (Section 4). 2. WHY PROHiBiTiOn? THe TWOFOLD mORaL OBLiGaTiOn FOR HaRmFUL SOCiaL nORmS according to Chambers, women's desire for breast implants is the product of a social context that links women's conforming to objectifying norms of physical appearance with beauty, success, and social appreciation. it therefore seems appropriate to focus on exposing and altering the circumstances that lead women to desire breast implants, rather than hindering women from having breast implants once these social circumstances have made their mark. Frequently discussed measures such as education campaigns and media and advertisement regulations try to achieve exactly this. education campaigns try to expose harmful and discriminatory norms as symptoms of a background culture of gender inequality and misogyny, hence battling harmful social norms by more comprehensive measures. media and advertisement regulations try to hinder modelling agencies or advertisement and movie companies from primarily engaging or displaying women who correspond to harmful and objectifying social norms. By increasing the diversity of female body types presented in media and advertisement, they aim to counteract harmful and objectifying beauty standards for women. i refer to these measures as conventional measures. Chambers is aware of conventional measures and acknowledges their role in undermining harmful social norms (Chambers 2008, 68). in fact, she seems to understand prohibition and conventional measures as complementary rather than competing. However, the question remains as to why we should consider the more provocative idea of prohibiting breast implants rather than simply make do with conventional measures that appear to be less problematic. according to Chambers, the question whether conventional measures are sufficient or need to be complemented with prohibition depends on how harmful the practice is that the harmful norm prescribes. Only if state prohibition does not seem "vastly disproportional" compared to the harm that it tries to prevent should we consider the option of prohibition (Chambers 2008, 198). By stating the case for prohibition like that, Chambers refrains from pointing out that her proposal in fact addresses a systematic blind spot of conventional apVolume 3, Issue 2 Should We Prohibit Breast Implants 41 proaches to harmful social norms. While measures like education campaigns and media regulations are helping to change harmful, discriminatory norms in the long run, they leave unaddressed the ongoing harm and injustice suffered by the individuals who are affected by the norms in the meantime. For the time it takes conventional measures to change a relevant norm, a period i refer to as transition period, the norm continues to impose a dilemma on individuals affected by it: to either pay the price of self-harm in exchange for socially regulated benefits that others acquire 'for free', or to forego the benefit altogether and hence live with the resulting disadvantages. Consider the case of breast implants. Here, women in the transition period either continue to undertake the painful and risky surgery so as to conform their appearance to an objectifying beauty standard, or they are sanctioned with psychological, economic, or professional disadvantages described above for failing to conform. Yet it seems that a society that is responsible for maintaining a harmful and discriminatory norm is also responsible for the harm and injustice that this norm inflicts on individuals during the period in which it is maintained.1 This suggests that societies which maintain a harmful, discriminatory social norm have a twofold moral obligation-not only to change or eliminate the norm in the long run, but also to address the norm's ongoing harmful and unjust effects on individuals. importantly, these two obligations coincide only in cases where the transition period is sufficiently short-i.e., where the norm would cease to exist shortly after means for eliminating it have been implemented. in such cases, it might be possible to eliminate the harmful norm before the individuals affected by it have experienced significant harm and injustice. as a result, both collective moral obligations could be discharged simultaneously by eliminating the norm. But this scenario looks like a mere theoretical possibility. in reality, harmful and discriminatory norms tend to be deeply culturally rooted, only allowing social progress at a snail's pace. even after the norms have been publicly acknowledged for the evil that they are, and conventional measures have been taken to challenge them, they nonetheless continue to exert their influence for long periods of time. in this case, conventional measures like education campaigns and media regulations will tackle the first moral obligation, but generally offer no way of addressing the second. They promote justice via social change in the 1. note that i will not address in this paper the question whether members of a society are under a retrospective collective obligation to address the current generation of a disadvantaged group for norm-induced harms that have been inflicted by their predecessors on the previous generation(s) of the disadvantaged group. Journal of Practical Ethics JESSICA LAIMANN42 long term, but effectively neglect to comabt the harm and injustice that is inflicted on individuals in the meantime. in accordance with Chambers' 'proportionality' consideration, one could admit that the second moral obligation is negligible in cases where the relevant harm appears relatively small, such as with regard to social norms requiring women to wear make-up. Yet, if the practice involves a painful and risky surgery that permanently forces someone's body to conform to a sexually objectifying beauty standard, such as in the case at hand, the ongoing infliction of harm in the transition period becomes an urgent moral concern alongside the need for long-term change. Hence, Chambers' proposal touches a crucial blind spot of conventional measures against harmful social norms. The question is whether we should also credit her proposal as a promising way of eliminating that blind spot. 3. PROHiBiTinG BReaST imPLanTS Chambers provides three arguments as to why prohibiting breast implants is principally a legitimate and effective way of undermining the harmful social norm that underlies the practice of breast implants. Her first argument aims to deflect the objection that her proposal is paternalistic. Her second argument can be understood as a non-paternalistic justification of prohibition. it states that, even if prohibition interferes with women's autonomy, it is justified in doing so because it achieves an overriding good-the elimination of the norm, and hence the promotion of gender equality. The third argument claims that prohibition is necessary to respect women as "desiring, choosing agents." i will show that the first two arguments are in fact best understood as instrumental arguments for prohibition, interfering with the choices and preferences of women today in order to improve the situation for women tomorrow. i will reject these arguments on the grounds that they impose unjust costs for social change on women who are affected by the norm today. The third argument, by contrast, provides a constitutive argument for prohibition: it defends prohibition as a necessary requirement for respecting women as equal human agents. By arguing that the requirements for respect are more complex than Chambers admits, and ultimately best served by a policy of informed choice, i reject the argument from respect, too, and conclude that overall the case for prohibition is unconvincing. Volume 3, Issue 2 Should We Prohibit Breast Implants 43 3.1 aUTOnOmY To begin with, Chambers argues that her proposal is non-paternalistic because it enforces rather than contradicts the preferences of the individual whose choice it interferes with. This argument refers to Danny Scoccia's account of paternalism (see Chambers 2008, 222). Scoccia argues that interference with an individual's choice for her own good does not violate the individual's autonomy if the choice fails to express accurately the individual's preferences, and the individual would consent to the interference if she were fully rational (see Scoccia 1990, 330-31, cited in Chambers ibid.). according to Chambers, a ban on breast implants fulfils this criterion because it would undermine the social norm that motivates breast implants. Prohibition would thus allow women to achieve the regulated benefits without undergoing painful and risky surgery-and this, says Chambers, is what women affected by the norm actually prefer (see Chambers 2008, 223). as a result, Chambers argues, prohibiting breast implants would increase rather than limit the autonomy of women. note that this argument is not simply equating autonomy with preferencesatisfaction. it is merely piggybacking on the fact that conflict with an individual's preferences is widely considered a necessary condition for paternalistic interventions with that individual's choice (see arneson 1980, Sunstein 1991, Thaler & Sunstein 2008). On most accounts of paternalism, i am not acting paternalistically unless i am limiting, changing, or manipulating your decision against your own preference. as a result, showing that prohibition does not conflict with the preferences of women would be a promising way to escape the charges of paternalism. But Chambers' argument turns out to be problematic. First of all, she presupposes that most women, even those who are willing to undergo breast surgery, actually have a preference for the non-existence of the social norm. She admits that prohibition of breast implants would undermine the autonomy of individuals who do not prefer achieving the benefit without undergoing surgery, but thinks that these are cases of "extreme particularity" and therefore do not support a decisive objection (see Chambers 2008, 226). However, if we think of the latter group of women as having internalised the social norm, it seems unlikely that their case will be a rare exception. individuals who have internalised a social norm do not merely have an instrumentalist awareness that corresponding to the norm will bring them desired advantages, but have made the norm part of their personal belief and value systems. This situation seems to be rather widespread. For example, it seems that many, if not most, people Journal of Practical Ethics JESSICA LAIMANN44 in Western societies hold a more or less conscious belief that thin people are more attractive than fat ones; that, as a woman, being physically attractive is conducive or even necessary for happiness and success in life; and, finally, that having breasts of a certain shape and size is part of that requirement. But if internalisation of social norms is the rule rather than the exception, most individuals affected by the norm will not have a preference for the norm's non-existence that outranks their preference for complying with the norm. Having been socialised in a society that endorses these norms, they might never have contemplated that the relevant norms could be different, or what their lives might be like if they were. Hence, the idea that individuals may not have a preference for the non-existence of the social norm provides a stronger objection to Chambers' proposal than she admits. Chambers could object that women who have internalised the norm that motivates cosmetic breast surgery are not fully rational, and that they would have a preference for the norm to be eliminated if only they would fully understand their situation. We might feel uneasy about basing state prohibition on such reasoning by conjecture, but for now, let us assume that the (actual or 'rationalised') preference structure of the large majority of women matches Chambers' description. assume that, after thoroughly contemplating their situation, most women agree that their desire to have breasts of a certain shape and size is the product of a patriarchal society that values women primarily as objects of male sexual gratification, and that they would be better off without the objectifying norm. Suppose that women therefore prefer, first, for the norm not to exist (which means being able to achieve the benefit without having to undergo surgery); and second, if their first preference is unattainable, women prefer to undergo surgery in order to attain the benefit. if women's actual preference structure indeed matches this description, Chambers suggests, prohibition would not be paternalistic, because it would realise their highest preference by destroying a norm which hinders achieving it. Under this assumption, however, Chambers' proposal still faces the problem of being based on an account of the individuals' preferences that is in relevant ways incomplete: it addresses women's preferences for different ends without considering the means by which these ends will be brought about. But means are important. if my desired end can only be brought about by means that i find objectionable, i might well decide to forego the desired end and settle for the second-best option. For instance, i have a preference for you giving me one million dollars over you not giving Volume 3, Issue 2 Should We Prohibit Breast Implants 45 me one million dollars, yet if you inform me that your means of obtaining the one million dollars is to kidnap a child and demand a ransom, i would probably change my preference with regard to the money. in the case at hand, Chambers presupposes that women prefer for the norm not to exist, but she does not consider whether women might object to achieving this end by banning cosmetic breast surgery. But women may prefer getting rid of the harmful norm and still reject prohibition of cosmetic breast surgery. This holds true even if (following Chambers and Scoccia), we require their decisions on the matter to fulfil some adequate conditions of rationality. Supposedly, such conditions for rationality would require, among other things, that women know that a ban on cosmetic breast surgery would result in a collapse of the social norm (assuming that it does), and that this would allow them to achieve the desired benefit without breast implants. However, there might still be women who consider prohibition an inappropriate response to harmful social norms. For instance, a woman might find it a problematic infringement of her and other women's authority over their own bodies to prohibit cosmetic breast surgery. She might think that women should refrain from having breast implants, but not be hindered to have them against their own wills. as a result, there might be women who principally welcome the elimination of the relevant norm but who object to the prohibition of breast implants, without thereby acting irrationally. now, let this point be granted, too, and assume that women do in fact have a preference for abandoning the social norm by prohibiting breast implants. This leads us to what i believe is the most pressing problem of Chambers' account: even if we grant all the above assumptions, it is still uncertain whether prohibition will fulfil the preferences of women who are affected by it. To see this, consider again Chambers' claim that her proposal enforces individuals' preferences. This claim crucially depends on the idea that prohibition will undermine the relevant norm within a time frame of less than one generation. if the norm stays in place for longer than that, individuals who are affected by Chambers' proposal can achieve neither their first nor their second preference: they cannot achieve the benefits without having breast surgery because during their lifetime, the norm is still regulating their desired benefits-and they cannot achieve these benefits by undergoing breast surgery since this option has been banned by the state. Chambers agrees that such a situation clearly has to be avoided (see Chambers 2008, 208). But it is not clear that her proposal can realistically do that. For one thing, it is not evident, and Chambers does not give us an idea of, how long the process Journal of Practical Ethics JESSICA LAIMANN46 of eliminating the harmful norm is likely to take. The history of Western beauty standards is ambivalent in that regard, hence only provides a very rough idea of the expectable time scale. Without directed interventions, some beauty norms seem to fluctuate at the scale of decades, while others vary very little over centuries. even if prohibition would succeed in undermining the relevant norm within a single decade, for women who are denied breast surgery early in the period of prohibition the costs might still be high and the benefits meagre. When the harmful norm finally ceases to function, these women will be in a different stage of their lives. They might have lived through a period continuously perceiving their bodies as inadequate and in need of surgical improvement, possibly at a time of their lives crucial to the establishment of one's sense of self-worth. Chances to enter a desired career in modelling, entertainment, or acting might have passed irretrievably. as a result, even in the best case scenarios, the net benefit of prohibition might be a very limited one for these women. This problem is augmented by the fact that it is unclear how significant a contribution prohibition would make in undermining the underlying norm over and above what could already be achieve by conventional measures like media and advertisement regulations. neither of these measures has been tested, alone or in combination. it might well be that what determines the impact of the norm is not so much the actual number of women who conform to it, but rather the fact that these women's bodies are highly overrepresented in the media, and are presented as more desirable, successful, or valuable than others. in that case, the contribution of media regulations would be substantial but the contribution of prohibition only marginal, hence probably insufficient for outweighing the costs it imposes on affected women. as a result, even if we grant all of Chambers' assumptions about women's preference structures, there are reasons to doubt that prohibition is in accordance with the preferences of those women who would be affected by it. 3.2 GenDeR eqUaLiTY One could object that there is an ambiguity about whom Chambers' proposal is primarily trying to help -women who are currently affected by the norm, or future generations of women. if we assume the former, as argued above, Chambers' proposal is likely to conflict with the preferences of those women who are affected by it, hence cannot be defended against the charge of paternalism on those grounds. But some passages suggest that Chambers might be more concerned with the harm and Volume 3, Issue 2 Should We Prohibit Breast Implants 47 inequality confronted by 'women in general' in a particular society, i.e. mostly future generations of women in that society (see Chambers 2008, 265). if that is the primary aim of Chambers' proposal, it would not be paternalistic despite conflicting with the preferences of those who are affected by it, because the interference no longer aims to promote their own good. instead, prohibition would be an interference with the autonomy of women today in order to reduce the inequality and harm suffered by future generations of women. But again, there are several problems with this argument. 3.2.1 THe PROBLem OF eFFiCaCY if Chambers' proposal is successful in the long run, future generations of women will no longer be subject to the harmful norm. But there are reasons to doubt that Chambers' proposal will be a particularly good or effective tool in achieving this aim. For one thing, as argued above, prohibition of cosmetic breast surgery will not erase or even significantly reduce the pervasive imagery that promotes the harmful norm. There will still be individuals who conform to the standard without surgery, and there will still be image editing programmes. all prohibition can achieve is to decrease the number of women whose bodies conform to the social norm. But by doing that, it also increases exclusivity. in some examples, such as body size or tanned skin, historic records suggest a positive correlation between the rarity of a physical characteristic and its appeal as a beauty standard. it is thus possible that Chambers' proposal increases rather than decreases the appeal and effectiveness of the social norm underlying cosmetic breast surgery. more importantly, even if prohibition succeeds in undermining the particular harmful social norm motivating breast surgery, the benefits for future generations of women might well be sparse. as Chambers acknowledges, the social norm under consideration is the product of a wider context of gender inequality and oppression. Yet, by focussing on particular social norms, her proposal is addressing the symptoms of gender inequality without challenging the underlying causes. Hence, it seems likely that she is battling a Hydra. norms regarding the size or shape of women's breasts might change or disappear, but unless the background issues of gender inequality and oppression are challenged, similarly harmful norms are likely to replace it. again, these arguments cast doubt on the idea that specific intervention in the form of prohibition has any substantial impact in the battle against harmful social norms and gender inequality above and beyond what could be achieved by conventional Journal of Practical Ethics JESSICA LAIMANN48 measures alone, especially if they are designed to address the underlying problem of gender inequality and the objectification of women in a more comprehensive manner. 3.2.2 THe PROBLem OF UnFaiR TRanSiTiOn COSTS Finally, assume that prohibition is an effective means for undermining harmful social norms. in that case, the previous discussion nevertheless suggests that Chambers' proposal involves unfair transition costs. To see this, consider the following toy account of transitional justice. assume that the alleviation of something wrongful, such as undermining a harmful and unequal social norm, in the long term requires that certain costs be paid in the short term. Who should pay the costs? in case someone can be identified as responsible for creating or sustaining the wrong, the obvious response would be to require them to pay. in the case at hand, the relevant wrong, i.e. the harmful and unequal social norm, has not been created or sustained by any specific individual or group of individuals. instead, though the norm likely results from values whose existence precedes that of most current members of society, it is currently sustained by 'society as a whole' in the form of many small interactions of its members that reproduce the underlying values. as a result, the responsibility for sustaining the social norm is a collective one. This suggests that the costs, too, ought to be paid collectively. Chambers' proposal, however, by suggesting to undermine the social norm by hindering women who want to have breast implants from having them, only affects women. One could argue that, like all members of society, women share responsibility for sustaining the social norm. 2 moreover, by undertaking the surgery, women who desire breast implants would further reinforce the harmful norm, hence take on additional responsibility for the norm's existence. Yet, unlike other members of society, women who are willing to undergo surgery are also the norm's primary victims. after all, their desire to have breast implants, according to Chambers' analysis, is simply an attempt to overcome the psychological, professional, or economic disadvantages that the norm imposes on them-costs which apparently weigh heavy enough for them to make a painful, risky, and expensive surgery an attractive option. Hence, instead of distributing the costs equally among those who are responsible for sustaining the social 2. acknowledging that the victims of the norm are largely women, while the beneficiaries of the norm are largely men, one could also argue that men bear primary responsibility and hence ought to pay the lion's share of the costs (see may & Strikwerda 1994). This would strengthen the case against Chambers' proposal, which put the costs exclusively on women. Volume 3, Issue 2 Should We Prohibit Breast Implants 49 norm, Chambers' proposal puts the lion's share of the costs on women-largely on those who are already most negatively affected by the norm's existence. Distributing of the costs for social change at the expense of those women who suffer the strongest disadvantages under the status quo effectively suggests fighting a form of oppression at the cost of the oppressed, hence is a problematic means of promoting justice and gender equality. it could be argued that this injustice is mitigated by the fact that those women who are the norms' primary victims would also be the primary beneficiaries of a ban on breast implants that undermines the harmful norm. But in the light of the previous discussion, we can see that the injustice is instead further augmented by a form of transitional injustice. as argued above, the timescale at which the mechanism for undermining social norms by prohibition operates is likely to be such that the individuals who pay the costs will enjoy the benefits only to a limited degree or not at all. if Chambers' proposal succeeds, future women would indeed no longer have to face the pressure to undertake unnecessary and harmful surgery. But women in the transition period pay the price of undermining a harmful social norm without reaping the benefits. instead, prohibition effectively deprives these women of their only available means for overcoming the psychological, economic, or professional disadvantages that the norm continues to impose. in sum, even if Chambers' proposal would in the long run prove effective in undermining the harmful norm and in promoting gender equality, this progress comes at a price. instead of being borne equally by those responsible for the norm's existence, the costs for undermining the norm are disproportionately shouldered by women who suffer mostly under it. 3.3 ReSPeCT i have argued that the first two defences of Chambers' proposal are problematic. Pace Chambers, prohibition is susceptible to paternalism charges because it may not be in accordance with the preferences of those affected by it. in addition, it achieves progress with respect to gender equality only by disproportionally burdening those who it claims to protect-individuals who are affected by the harmful, discriminatory norms. i will now consider a third defence of Chambers' proposal, which says that the prohibition of breast implants is necessary to provide respect for women. Before i begin, note that Chambers' argument about respect is logically independent from the argument regarding gender equality in the previous section. The Journal of Practical Ethics JESSICA LAIMANN50 previous argument about gender equality addresses the instrumental value of prohibition in undermining the harmful social norm, and in advancing gender equality more generally. The argument about respect is also concerned with gender equality, but is looking at prohibition in a constitutive rather than in an instrumental way. it is not considering prohibition primarily as a tool for undermining the norm and promoting gender equality, but instead as a communicative act that is constitutive of respecting women as equals. Hence, prohibiting breast implants could be detrimental or neutral for promoting gender equality in the instrumental sense-for instance because it is ineffective, or makes the norm more rather than less powerful-and, at the same time, contribute towards gender equality in the constitutive sense because it is an act of respecting women as equals. Thus, the question in the following is whether the benefits of prohibition in its constitutive role can make up for unjust costs that it imposes in its instrumental role by curtailing women's autonomy and disproportionally burdening them in the quest for social change. For Chambers, the constitutive case seems to be a clear one. The message communicated by allowing a woman to have breast implants, Chambers argues, is that her feeling of inadequacy with natural breasts, and her resulting desire to undergo painful and dangerous surgery "are understandable and worthy of respect" (Chambers 2008, 198-199). according to Chambers, we are thereby also expressing respect for the social reality in which women develop the desire to have breast implants, hence express our support for the status quo (ibid.). Prohibition, by contrast, is an attempt at saying "you as an individual are worthy of more respect than is compatible with you undergoing breast surgery [for instance] in an attempt to become successful" (Chambers 2008, 200). in view of this, Chambers concludes that it is impossible to respect women's desire to have breast implants and at the same time respect them as "desiring, choosing agents" (Chambers 2008, 198). Only by prohibiting breast implants can we voice criticisms of the status quo and the role of women in it, and hence respect women who are affected by the harmful norm. This argument forcefully addresses a valid concern, yet i believe that the issue of respect in the context of harmful and discriminatory social norms is more complex than Chambers acknowledges. in the following, i argue that, once we consider a more nuanced account of respect, impeding women from having breast implants may not be necessary, and, in fact, may even be detrimental, to respecting them as equal agents. To begin with, it is important to understand how Chambers' discussion of respect Volume 3, Issue 2 Should We Prohibit Breast Implants 51 is connected to concerns about harm. Chambers' argument about respect suggests that respecting women requires us to prevent them from inflicting harm on themselves, at least if that harm is the product of a discriminatory social norm. assuming that risky illegal alternatives can be kept at bay, prohibiting breast implants might be an effective way of protecting women from the physical, status, and economic harm that this procedure involves. i will refer to these harms as harms of compliance. Yet, as argued in Section 2, the harms that are caused by the social norm underlying breast implants go beyond the physical, status, and economic harm of having breast implant surgery. They also include psychological harm, such as the internalised feeling of inadequacy that is apparently pressing enough to make a painful and dangerous surgery an attractive option for many women; and economic and professional harm in cases where one's professional success is impeded by not conforming to the norm. i will refer to these harms as harms of non-compliance. Chambers acknowledges harms of compliance and harms of non-compliance as relevant in the argument about prohibition (Chambers 2008, 210). Yet, her argument about respect focusses on the harms of compliance (mostly physical harm and status harm) and largely neglects the effect prohibition might have with regard to the harms of non-compliance. On Chambers' account, respecting women requires protecting them from the harms of compliance by legally preventing them from having breast implants. as the discussion in Section 3.2 suggests, this strategy has troublesome effects. Prohibiting women from undertaking breast implants will soothe neither the psychological, nor the economic or professional harm that they hoped to alleviate by having breast implant surgery. instead, it forces women to confront these harms against their own choice for as long as the norm remains effective-a period which, as i have argued, might stretch over several decades. as a result, Chambers' suggestion for how to best repect women involves exposing them to the harms of non-compliance which, judging from their sincere desire for surgery, for them seems to constitute the greater of two evils. Take a moment to note the crucial role of the argument about respect in justifying prohibition. From a merely instrumental perspective, prohibition would effectively expose some women against their own choice to psychological, professional, and economic harm in order to improve the situation for future generations of women. This justification, i argued, is problematic because it effectively suggests ending a form of oppression at the cost of the oppressed. But if Chmabers succeeds in providing an alternative, constitutive justification, accotding to which protectingJournal of Practical Ethics JESSICA LAIMANN52 women from the harms of compliance is a necessary requirement for respecting them, even at the costs of exposing them to the harms of non-compliance against their own will, the problem above loses its force. However, it is not obvious that Chambers' way of negotiating the different kinds of norm-induced harms is the only, let alone the best, way to provide respect for women who are affected by discriminatory social norms. Respecting women may require us to equally protect them from all the unjust harms that the norm inflicts on them, or to protect them first of all from those harms that they themselves judge to be the most pressing ones. Thus, an objection to Chambers' account of respect would say that the very fact that many women decide to have breast implants in spite of the harm the procedure involves, demonstrates that Chambers is focussing on the wrong sort of harms. These women, so the argument goes, disagree with Chambers' understanding of what it means to respect them. Their decision bears evidence that for them, the psychological, economic, or professional harms of non-compliance are of more pressing concern than the physical and status (and economic) harms of compliance. To them, the choice to have breast implants might be an act of self-care in unfavourable circumstances, even if it amounts to nothing more than trading one set of unjust harms for another. Prohibition, by contrast, not only deprives these women of authority over a decision with regard to their own bodies, but ignores that, from their own perspective, the physical and status harm of breast surgery might be a less humiliating and painful experience than non-conformity with the harmful norm. To this, Chambers could respond that most women's decision to have breast implants may not correctly reflect their weighing up of all the different harms involved. Women who decide in favour of breast implants, she could argue, might be unaware of the status harm that undergoing surgery would inflict on them, because status harm is much more elusive than physical and economic harm. Unlike the physical and economic harms and risks of cosmetic breast surgery, status harm does not regularly feature on patient leaflets in cosmetic clinics, or appear among the top hits of an internet search for 'breast implants surgery.' instead, status harm is often disguised and requires perspicacious social analysis to become visible. most women who desire breast implants will therefore not be aware that this procedure involves complying with a harmful norm that casts them as inferiors. as a result, Chambers could object, a woman's choice to have breast implants is likely to be based on information that are incomplete in crucial respects, and should therefore not be understood as an informed decision that demands our respect. Volume 3, Issue 2 Should We Prohibit Breast Implants 53 However, the fact that someone's decision to engage in a self-harming practice is based on their incomplete understanding of the harms involved does not usually suggest prohibition of the practice as a go-to remedy in the name of respect. instead, it seems that our response for respecting individuals as desiring, choosing agents would be to ensure that all the relevant information is available to them. Hence, it seems that respecting women as desiring, choosing agents first of all requires providing them with information about the status harm that breast implants surgery involves. moreover, insofar as a woman's decision to have breast implants is enforcing the harmful norm and is thus not only harming herself but also other women in the present and future, an informed decision should also require information about these negative externalities. To this, Chambers might reply that a full understanding of the status harm and negative externalities involved in having breast implants is simply incompatible with the deliberate decision of having them. She could argue that a woman cannot at the same time be aware that breast implants cast her, and other women who feel compelled to having them, as an inferior object of male sexual desire and yet believe that having breast implants is a prudent thing to do in her situation. a woman's decision to have breast implants, Chambers could argue, can only be a symptom of her having internalised the idea that women with natural breasts are indeed inadequate. Hence, Chambers might object, there is no need to have women reconsider their decision about breast implants in the light of information about status harm, because we already know what their decision will be. There are several ways to respond to this. First, one could insist that allowing women to make an informed decision based on information about all the relevant harms is nevertheless a requirement of respect in this situation-hence, that respecting women as desiring, choosing agents requires us to provide them with resources to critically reassess their decision, even if we could already be sure what the outcome of that reassessment will be. Second, one could argue that women's reasons for having breast implants, and the meaning of that decision, might be more nuanced and reasoned than the above objection admits. Women may fully understand and oppose the harmful norm that requires them to have breast implants and yet feel that having breast implants is, all things considered, the most prudent option in their situation. Chambers would certainly agree that understanding and opposing harmful, discriminatory social norms does not prevent women from being affected by them. Hence, a woman might be fully aware of the problematic nature of her nagging feeling of Journal of Practical Ethics JESSICA LAIMANN54 inadequacy with natural breasts. Yet, she might find the feeling hurtful and distracting; or she might find that dealing with it on a daily basis is simply taking too much of her time and energy-time and energy that could be more productively spent on a career in science, or, as it were, on plotting a feminist revolution that will eradicate these concerns for good. in either case, the woman's decision to have breast implants would not express a naïve endorsement of the norm that motivates it. it would rather be a costly but reasoned compromise which negotiates the burdens of the norm in a way that best allows her to realise her personal goals and values. Furthermore, since the decision to have breast implants is first of all a matter of women's authority over their own bodies, respecting women requires that we leave it up to themselves how to weigh the problem of negative externalities into that decision. as a result, we can agree with Chambers that respecting women requires altering the social reality that leads them to desire breast implants, and at the same time object to the idea that we should prohibit women from acting on that desire. instead, providing women with respect requires that we make them aware of what precisely they are buying into when opting for cosmetic breast augmentation. now, after reconsidering their decision critically, and recognizing the harms that confront them either way, they might still come to the conclusion that having breast implants is overall the most prudent thing to do. That very decision would also be evidence for the fact that women are not willing or able to make the sacrifice Chambers' proposal asks them to make in order to speed up the norm-eliminating social process leading to a better future for other women. One might still hold that this choice would be lacking in self-respect or egotistic. But to prohibit breast implants, and hence to force women to face the harms of non-compliance against their own judgement, is to further disrespect them as desiring, choosing agents. as a result, the only appropriate reaction, in the name of respect for women, is to continue to criticise and challenge the disrespectful circumstances which make this choice an attractive one in the first place. 4. an aLTeRnaTiVe PROPOSaL The discussion of Chambers' proposal illustrates how trying to address the problem of harmful, discriminatory social norms pulls us in opposite directions. The reason for that, i have argued, is the twofold moral obligation posed by the existence of these norms. While the obligation to eliminate the harmful norm calls for Volume 3, Issue 2 Should We Prohibit Breast Implants 55 powerful measures of undermining it, which might additionally burden those who already suffer most under the norm, the obligation to address the ongoing norminduced harm requires that we, at best, alleviate these harms immediately, and, at least, refrain from worsening the situation for women affected by them. Chambers' proposal, in principle, recognizes not only the first, but also the second moral obligation. On these grounds, we should expect her proposal to be an improvement upon conventional measures for addressing harmful social norms. Yet, a closer discussion of the details of Chambers' defence revealed substantial problems which reflect the tension between the two moral obligations. even if prohibition is a powerful tool for undermining social norms that motivate a self-harming practice like breast implants – which, i argued, is uncertain – it might come at significant costs to the individuals who are affected by it: Chambers can neither refute the charge that her proposal might contradict rather than enforce women's preferences, nor demonstrate that prohibition is a requirement, or even a good way, of respecting women. as a result, her defence of prohibition is either unconvincing (as a requirement of respecting women), or unduly sacrifices the second moral obligation in favour of the first by effectively proposing to fight oppression at the costs of those currently oppressed (as a means to undermine the harmful norm). Overall, prohibition is then not a good way to address the twofold moral obligation entailed by harmful and discriminatory social norms, at least in the case of breast implants. in the remainder, i develop an alternative proposal based on four desiderata that aim to avoid the problems of Chambers' proposal. note that, like prohibition, this proposal should not be understood as replacing conventional measures like education and media regulations. instead, it is meant to serve a complimentary role that takes into account the second moral obligation which conventional measures tend to neglect. in the previous discussion, i have identified four main problems of Chambers' proposal that ought to be avoided by a better alternative. First, prohibition disregards women's own informed judgement as to whether or not they should have breast implant surgery, hence disrespects them as desiring, choosing agents. Second, while (compulsorily) protecting women from the harms of compliance, prohibition does not address the harms of non-compliance, but instead might effectively expose women to these against their own choice. Third, prohibition risks promoting social change in an unjust way by undermining a harmful norm largely at the costs of those affected by it. Fourth, effectively, prohibition is biased in favour of the first moral obligation while neglecting the second. against this background, i propose the folJournal of Practical Ethics JESSICA LAIMANN56 lowing four desiderata for an alternative proposal. The alternative proposal should, first of all, make the decision to have breast implants a matter of truly informed consent. While the ultimate decision about having breast implants ought to remain with the individual woman, she needs to make that decision in light of knowledge about the discriminatory and objectifying nature of this practice. Second, the proposal should acknowledge both kinds of norm-induced harms, harms of compliance and harms of non-compliance, as collective wrongdoings against women which. This means that, until both kinds of harms are prevented, women are owed recognition and redress for having been wrongfully harmed by society. Third, since the existence of the harmful social norm constitutes a collective wrongdoing against women, the proposal needs to distribute the costs for social change and redress collectively, or at the very least has to refrain from imposing the lion's share on the affected women. Fourth, the proposal needs to attend adequately to both moral obligations and not unduly neglect one in favour of the other. How do we implement these desiderata? With regard to the first desideratum, the matter seems to be quite straightforward. in addition to education campaigns that raise general awareness of the discriminatory and objectifying nature of the practice of breast implants, the relevant information could be specifically communicated as part of the physician-patient-consultation, or on the medical consent form that patients are required to sign before breast implant surgery. The relevant information would not only include reference to the status harm that having breast implants might entail, but could also feature information about the harmful effects breast implants might have on other women by increasing the acceptance and influence of the relevant norm. The second desideratum requires addressing both kinds of unjust harms that are inflicted by the social norm, harms of compliance and harms of non-compliance. The discussion of prohibition suggests that, unless the harmful norm is fully eliminated, it is in practice impossible to prevent women from being exposed to either one or the other. as with other cases where an agent (individual or, as assumed in this case, collective) is responsible for wrongfully harming someone, the agent is obliged to provide some form of redress to the victim. if we assume that a society, by maintaining harmful norms, wrongfully inflicts these harms on women, members of the society would thus face a collective liability to redress the affected women. according to this idea, women would be entitled to compensation for the unjust harms they face due to the harmful social norm. One obvious way to implement such means Volume 3, Issue 2 Should We Prohibit Breast Implants 57 for redress would be to follow the common judicial practise of redressing not only economic and professional, but also physical and psychological harms by monetary means. monetary compensations seems to be a very crude measure for redressing the diverse kinds of harms inflicted by the relevant social norm. moreover, overestimating monetary compensation as a means to restore what women's life would have been without the degrading social norm might itself constitute a form of disrespect. Yet, despite its obvious shortcomings, monetary compensation might fulfil both a symbolic and a practical role in redressing the harms of the social norm. Symbolically, monetary compensation could at the very least express acknowledgment that the norm-induced harms are in fact a form of collective wrongdoing. in its practical role, monetary compensation could be used flexibly by each woman so as to best ameliorate the harm that the norm has caused her individually. The idea of monetary redress may thus rightly invoke mixed feelings, and requires a more detailed discussion than i can provide here. Yet, in lack of a better alternative, i suggest we adopt it as a possible form of redress and consider in more detail what this suggestion would entail. With regard of harms of non-compliance, it would entail that women are entitled to compensation for the psychological, professional, or economic harms they suffer due to not conforming to the harmful norm. Yet, despite the option of monetary compensation for these harms of non-compliance (and their awareness of status harm) women might still opt in favour of complying with the harmful norm. How, adhering to the second desideratum of addressing the harms that occur either way, should we proceed in these cases? it seems that, if a society is responsible for facing women with the dilemma of choosing between the harms of complying and the harms of not complying with a certain social norm, it is responsible for the harms that it inflicts on women on either horn of the dilemma. Hence, the fact that a woman declines compensation and opts for surgery does not exculpate the society that maintains the norm which motivates the woman's decision from redressing the harms that she faces due to having the surgery. if anything, her decision is evidence that the crude attempts at monetarily mending the psychological, economic, or professional harms are insufficient. as a result, the harms that she is facing due to the surgery are equally unjustly inflicted on her by society, hence equally mandate compensation.3 This would entail that women who decide to have 3. Since i believe that the idea of monetary compensation for status harm is absurd and selfdefeating, the claim for compensation is meant to apply only to the physical and economic harms of compliance, leaving the problem of status harm unaddressed. Journal of Practical Ethics JESSICA LAIMANN58 surgery are entitled to monetary compensation not only for the immediate and longterm physical harms they may suffer due to the operation, but also for the costs of the operation itself, as well as any related costs of medical treatment. in other words, the second desideratum of redressing the unjust harms of social norms effectively requires that we subsidize breast implant surgery. This has implications with regard to the fourth desideratum which will be discussed below. Before that, consider briefly the third desideratum, which demands that the costs for undermining a harmful social norm be borne collectively, or at least do not disproportionately burden those affected by the norm. The alternative proposal developed here is meant to compliment education campaigns and media and advertisement regulations with compensation payments for norm-induced harms. insofar as all of these measures are financed collectively by the society that maintains the harmful norm, and do not impose further harms on affected women, this desideratum is fulfilled. With regard to the fourth desideratum, which requires an adequate balancing of the obligation to undermine the harmful norm on the one hand, and the obligation to address the ongoing harming of women on the other, the situation is a little more complex. While the conventional measures, as argued above, primarily target the first moral obligation, the compensation payments for norm-induced harm are meant to target the second moral obligation. Unfortunately, we can again identify a problematic tension between these two parts of the alternative proposal. This is not so much the case with the compensation payments for harms of non-compliance. To the contrary, as a welcome side effect, they are likely to decrease the incentives for having breast implants, hence support conventional measures in undermining the norm. But there is a conflict with regard to compensation payments for harms of compliance, i.e. with regard to the subsidy and compensations for breast implant surgery. These monetary compensations for the harms of compliance are likely to encourage women to have breast implants, hence contradicting the first moral obligation. it is important to distinguish several scenarios of how the compensations might achieve this, for not all of them are equally problematic. For one thing, these compensations could allow women who firmly desire to have breast implants but cannot afford them to act on that desire. On this understanding, compensation for the harms of compliance constitutes not so much an encouragement to undertake breast surgery but removes a decisive financial obstacle faced by some women. However, this aspect seems to be a desirable feature of the subsidy and compensation proposal Volume 3, Issue 2 Should We Prohibit Breast Implants 59 for it provides poor women with the same choice as more wealthy women. it thus enables all women to escape the psychological, economic, or professional harms of non-compliance via surgery given that their informed judgement is that this is the best choice for them. at the same time, insofar as a subsidy and compensation payments for breast implant surgery increases the total number of women who have the surgery, there is a risk that having breast implants becomes more commonplace and acceptable. as a result, the harmful norm would become even more powerful and the pressure on women to have the surgery would increase. Finally, compensations for the harms of breast implant surgery would communicate what Chambers' fears legalisation of breast implants communicates: that the harmful norm underlying the decision to have breast implants is worthy of respect, and that women's feelings of inadequacy about their bodies are appropriate and require a surgical, rather than social, intervention. The latter two scenarios both describe ways in which compensation payments for harms of compliance, in trying to address the injustice imposed by a harmful norm, work against the long-term goal of undermining the norm. Subsidy and compensation payments may increase the norm's power by making breast surgery more acceptable or required, or they may strengthen the norm by communicating that it is worthy of respect. as a result, an alternative proposal that includes subsidies and compensation payments for having breast implants would fulfil the first three desiderata: it would make breast implant surgery a matter of informed consent; it would redress both kinds of norm-induced unjust harms, and it would distribute the costs for undermining the norm and redressing its unjust harms in a collective way. However, by increasing the respectability and acceptability of breast implants surgery, this proposal would make the harmful norm even more powerful and hence undermine the long-term goal of eliminating it. The proposal, then, would fail with respect to the fourth desideratum, because its attempts at addressing the harms of compliance would unduly compromise the first moral obligation to eliminate the norm. in conclusion, a suitable alternative to prohibition would combine education campaigns and media regulations with compensation payments for the harms of non-compliance, but would need to refrain from subsidising and compensating having breast implants. Journal of Practical Ethics JESSICA LAIMANN60 5. COnCLUSiOn Despite its nominal acknowledgement of the twofold moral obligation with regard to harmful and discriminatory social norms, prohibition, i argued, overall does not provide a good way to respond to both obligations. it constitutes either a problematic form of paternalism, a misguided way of respecting women as desiring, choosing agents, or undermines a harmful norm at the cost of those affected by it. instead, i showed, a combination of education campaigns and media regulations together with a system of compensation payments for harms of non-compliance provides the best way to address both moral obligations in combination. Acknowledgements: This paper has benefited enormously from insightful discussion with and comments from Tom Sinclair, Maxime Lepoutre, Cecile Fabre, the participants of the Political Theory Research Seminar MT 2014/15 in Oxford, the participants of the GAP.9 Conference 2015 in Osnabrück, as well as one anonymous reviewer of the Uehiro Prize for Practical Ethics. ReFeRenCeS arneson, Richard J. (1980): 'mill versus Paternalism.' Ethics 90 (4), 470-489. Chambers, Clare (2008): Sex, culture, and justice. The limits of choice. University Park: Pennsylvania State University Press. may, Larry. & Robert Strikwerda (1994): 'men in Groups: Collective Responsibility for Rape,' Hypatia 9, 134-151. Scoccia, Danny (1990): 'Paternalism and Respect for autonomy.' Ethics 100 (2), 318-334. Sunstein, Cass R. (1991): 'Preferences and politics.' Philosophy & Public Affairs 20, 3-34. Thaler, Richard H. & Cass R. Sunstein (2008): Nudge: Improving decisions about health, wealth, and happiness. 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