The Ethics of Lip "Tie" Surgery by Alison K. Hazelbaker, PhD, IBCLC, FILCA, CST-T, RCST, PPNE

Lip ties have been a hot topic in the breastfeeding world since 2012. They are the new go-to when breastfeeding issues are not easily resolved. But there is no research showing how or if lip ties affect breastfeeding. If there is no evidence showing that lip ties affect breastfeeding, how then is it ethical to refer for surgery? It’s not. Here’s why.

Biomedical Ethics

Biomedical ethics is a field of study dedicated to applying values and judgments to the clinical practice of healthcare. Lactation consultants must abide by these ethics as well. The principles of biomedical ethics are veracity, autonomy, beneficence, nonmaleficence, role fidelity, confidentiality, and justice. Let’s take a closer look at some of these principles.

Veracity – Veracity is the expectation that both the practitioner and the patient are telling the truth, both actual truth and by not withholding information. The patient must tell the truth because to lie or to withhold information means that the practitioner does not have the necessary information to make an accurate diagnosis or care plan. The practitioner must tell the truth because to lie or withhold information means that the patient does not have the necessary information to make an informed decision about their healthcare.

Autonomy – Autonomy is the principle of ownership. Patients have the right to choose their care and act on those choices. Autonomy includes the right to have all the information regarding their care, and that information given in a way they understand. It also includes the power to act on their decisions. Having information about their situation means nothing if they are then not able to choose the care path that they want. And finally, it also means that the patient must respect the autonomy of the practitioner as well.

Beneficence – Beneficence, as an ethical term, means that the practitioner has a duty to benefit the patient, and do their best to uphold health.

Nonmaleficence – Nonmaleficence is the expectation that practitioners will do their best not to inflict harm, or minimize the harm, like in the case of side effects for necessary medications. Nonmaleficence is different from beneficence in that nonmaleficence is not doing harm, while beneficence is preventing and removing harm and doing good.

Ethics and Lip Tie Revisions

How then do these ethics apply to lip tie revisions?

Veracity – What truth do we know, via evidence, about lip tie and breastfeeding? We don’t. There is no evidence showing that lip tie is a condition that affects breastfeeding, the prevalence rates of lip tie, or if lip tie revisions are correlated with improved breastfeeding relationships. There is no assessment tool, evidence-based or otherwise, to check for a lip tie. There is one classification system, but that system does not take function into consideration, and therefore cannot be used as a clinical assessment tool. Currently, there is no way to assess what visual characteristics and what functional characteristics are involved in lip ties. So, if there is no assessment tool, there is no research showing that lip ties affect breastfeeding, and there is no research showing that lip tie revisions improve breastfeeding outcomes, there is no way to diagnose or refer for revision while upholding the principle of veracity.

Autonomy – This follows closely on veracity. For the patient to exercise their autonomy, they have to be given the full truth regarding their situation. The full truth regarding lip ties is that there is no evidence. Because of this lack of evidence, some practitioners look to their anecdotal experiences and express those as actual evidence. This is called paternalism. It is the withholding or limiting of information to lead a patient into the decision that the practitioner thinks is best. It is a direct violation of autonomy.

Beneficence – How can lip tie revisions be beneficial if there is no evidence showing that they are? Some practitioners argue that they have seen positive change after lip tie revisions. Other practitioners, and numerous mothers, report no change. If the positive change that some people see is so variable, is it ethical to propose that there will be positive change? Will there probably be positive change? Maybe there will be positive change? It is unlikely to change? What is not known is at what rate lip tie surgery is successful, or needed. Considering that, it cannot be beneficent to revise lip ties.

Nonmaleficence – Lip tie divisions are surgery. They are relatively quick surgeries, but they are surgeries nonetheless. There is risk involved. There is pain involved. Depending on how the specific practitioner performs the surgery, there can be trauma involved. In other words, harm is done. Yes, there is always harm done during surgery. But, the benefits must outweigh that harm. Do the benefits of a lip tie surgery outweigh the harm? There is no data on the success rate of lip tie surgery. If there is no data on the success rate, there is no way to quantify if the benefits outweigh the harm, because there is no way to quantify the benefits.

Lip tie may very well be a condition that affects breastfeeding. But, it might not. Until we have more research, it is not ethical to refer for lip tie surgery.

References:

1. Brooks, E.C. (2013). Legal and Ethical Issues for the IBCLC. Jones & Bartlett Learning.

2. Edge, R.S. & Groves, J.R. (2006). Ethics of Health Care: A Guide for Clinical Practice. Thompson Delmar Learning.