Abstract
BACKGROUND: Unlike criminal defense with its cab-rank duty, surgeons are constrained by nonmaleficence. This review examines when declining aesthetic surgery requests constitutes ethical care rather than prejudice. OBJECTIVES: To identify professional standards and empirical evidence guiding ethical decision-making when surgeons consider declining aesthetic surgery requests, and to provide a framework for principled refusal. METHODS: Narrative review of professional standards (GMC, RCS, ASPS, ISAPS), outcome data on higher-risk procedures, comparative analysis of jurisdictional safeguards, and ethics literature from plastic surgery. PubMed searches used terms: [(aesthetic surgery OR cosmetic surgery) AND (ethics OR informed consent OR patient selection OR refusal OR body dysmorphic disorder)] for 2014-2025, supplemented by professional society websites. RESULTS: Global demand reached 38 million aesthetic procedures in 2024. Ethics discourse remains underrepresented (approximately one in 1000 articles), with autonomy disproportionately emphasized over beneficence, nonmaleficence, and justice. Abdominoplasty complications cluster around 2-4%; gluteal fat grafting carries elevated mortality. Modifiable risks include nicotine, cannabis, and GLP1 therapy. Body dysmorphic disorder prevalence approaches 18.6% among candidates. Contemporary guidance emphasizes surgeon-led consent, cooling-off periods, psychological screening, and discretion to decline when benefit is doubtful. Ethically defensible refusal requires articulable clinical reasons, documentation, and alternatives-never moral disapproval. CONCLUSIONS: Structured frameworks applying the four bioethical principles-autonomy, beneficence, nonmaleficence, and justice-provide actionable guidance. Principled refusal, when clinically indicated and compassionately explained, is not failure but expression of professionalism. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .