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Kudos to Ringel¹ for addressing the central moral issue facing dermatology. She cogently and with surgical precision dissects the cosmetic surgical dilemma and comes to the conclusions that aging is not a physical illness (no surprise there), that it is not appropriate to treat "mental illness self-esteem issues" with surgery, and that the contractual relationship between the physician and the patient should be held to a higher standard than business. One can only wonder if the extraordinary pressures being placed on the specialty are being responded to in a less than extraordinary manner by members of our profession and the American Academy of Dermatology. Managed care, gatekeepers, reduced reimbursements, competition from primary care givers and other specialists, and our generally shrinking piece of the medical pie seem to be the driving force for dermatologists to read their own slides rather than use dermatopathologists, dispense medication in their offices rather than . . . [Full Text of this Article]