When Patient Preference Does Not Settle the Matter: Structural Ambiguity in Cosmetic Gynecology

Patient preference commonly guides shared decision-making by allowing patients’ values and priorities to shape the course of care. Cosmetic gynecology, however, poses a revealing challenge to this role because patient preference is expected to guide procedures whose object, aim, means, and standards of success may themselves remain underdetermined. Existing accounts of clinical ambiguity focus largely on incomplete, probabilistic, or conflicting information, while the complexity of ambiguity arising within different dimensions of clinical practice remains comparatively underexplored. In this paper, I focus on this type of ambiguity by distinguishing four forms of what I call practice-level ambiguity: normative, diagnostic, technical, and outcome ambiguity, concerning respectively what the procedure seeks to achieve, what it addresses, how it is performed, and how its success is assessed. I then argue that these forms are structurally interdependent because how one is understood bears on how the others are interpreted within clinical practice—what I call structural ambiguity—and that its relationship with patient preference is bidirectional: patient preference helps shape how a procedure is understood, pursued, and evaluated, while structural ambiguity, in turn, shapes how patient preference is interpreted in clinical deliberation. I conclude that attending to structural ambiguity expands the role of patient preference in shared decision-making beyond what the patient chooses to how the procedure itself is understood, pursued, and evaluated.