Ethics in Aesthetic Medicine

This article is geared towards other medical professionals, and is a brief reflection on the ethics of cosmetic medicine, through the guiding four principles of medical ethics. Understanding aesthetic medicine in relation to its ethical context begins with appreciating the complexity inherent within it.

The popular perception around cosmetic procedures can vary. There are instances when the ethics surrounding aesthetic medicine are easier to appreciate – such as in the case of reconstructive surgery to restore form and function after a traumatic disfigurement or breast reconstruction following cancer. However, in popular culture there are many instances of patients having treatments on non-pathological tissue or for purely cosmetic concerns, sometimes to the extent that it calls into question the ethics and standards of the doctors performing these procedures. There can be issues surrounding whether procedures are performed safely with the patients’ best interests in mind, or for financial gain.

The aesthetic sector in the UK is quite controversial, as it is quite unregulated in comparison to other countries in the European Union. While non-surgical cosmetic procedures are performed by licensed medical practitioners (like doctors, nurses, and dentists), they can also be performed by non-medical practitioners such as beauticians. While botulinum toxin is a prescription medication, the current legislation is vague and allows for non-prescribers to administer these treatments. This was highlighted by the Keogh Review in 2013. This review attempted to bring to light concerns about this lack of regulation, and that there was a risk to public health and safety in allowing non-medical practitioners to deliver these treatments, especially in the case of dermal fillers. Vascular occlusions are by definition a medical emergency, and they can only legally be dealt with by a trained medical practitioner who has access to hyaluronidase and other prescription medications.

In other words, like with any other medical intervention, non-surgical cosmetic procedures come with risks. An ethical practitioner knows what these risks are and how to minimise them with extensive education and training, and knows exactly how to manage these risks in the worst-case scenario if they were to occur. Only medically-qualified practitioners who are answerable to professional bodies and are licensed prescribers fit this description.

The General Medical Council (GMC) has authority over all practitioners registered with the GMC, including doctors who practice aesthetic medicine. The GMC has released specific guidance relating to the practice of aesthetic medicine, and the minimum standards that it expects doctors to meet. This was published in 2016 in a document titled Guidance for doctors who offer cosmetic interventions.

This guidance had keys aims relating to clarifying the appropriate training and experience required to practice safely in the field. In other words, practitioners must make sure that they are working within their own competencies. As well as this, doctors must demonstrate continuing professional development and a commitment to lifelong learning, making sure that they are up-to-date in aesthetic medicine as a specialty. This includes going to conferences and attending courses to maintain knowledge and practical skills. Adherence to the guidelines is supposed to be assessed during the revalidation process, and failure to maintain these standards could theoretically put your medical registration at risk.

The GMC produced these guidelines in response to the Keogh Review, published in 2013. However, while these exist as best practice standards, they don’t tend to be strictly enforced by an overseeing body within the practice of aesthetic medicine, leaving it up to individual practitioners to decide how closely to adhere to the guidelines, in accordance with their own personal ethics. However, in response to the Keogh Review, the government mandated for Health Education England (HEE) to be involved in setting out appropriate credentials for non-surgical cosmetic interventions. In 2016, HEE published Qualification requirements for the delivery of cosmetic procedures. In essence, this set of guidelines recommends that any medically licensed practitioner engaging in Botox or dermal filler treatments should obtain a Level 7 qualification.

Examining medical aesthetics specifically via the broad framework of the four pillars commonly used within medical ethics can be useful. This involves exploring issues of justice, autonomy, beneficence, and non-maleficence.

Cosmetic treatments can correct issues that patients feel are stigmatising and cause them distress, affording them an opportunity to live free of stigma or discomfort related to their physical appearance. This can relate back to the concept of justice, by allowing “people chances for a good life.”

Patient autonomy is at the forefront of the field, as patients often approach medical practitioners themselves seeking out specific treatments. In fact, this is a field where patient autonomy is extremely important, as patients ultimately dictate how they wish to appear with guidance and advice from the clinician. However, it is important this autonomy is not negatively influenced in any way. A client-centred approach must be at the forefront of our ethical aesthetic medical practice always. The HEE has made it clear that it is the practitioner’s responsibility to discuss every aspect of a procedure with a patient, in order to ensure informed consent and to adequately assess suitability for treatment. A client-centred approach means we are not trying to “sell” to the patient, but rather we are trying to elicit their specific concerns, and offer realistic solutions to those concerns.

Autonomy also means that the patient has been consented to a treatment appropriately. Simply agreeing to something is consenting, and people can consent to a variety of things every single day. However, consent has a very specific definition within the medical context, and that most important aspect of that is that consent in medicine must be informed. That means, that you must supply the patient with all the information that is necessary for them to make an informed decision. This includes information about benefits as well as risks. Any information that a patient deems to be important must be included, and it is the responsibility of the practitioner to anticipate what this could be. In other words, if there is information that having been withheld, a patient learns at a later date, and then states, “If I had known that I would never have agreed to this,” the practitioner in this case has failed in their duty to ensure informed consent in the patient.

Consent is also closely tied into the concept of capacity, and the practitioner must know that a patient has capacity to make a decision, otherwise the consent in not valid. While capacity is always assumed, it means that a patient must have the ability to understand and retain information, to weigh up the risks and benefits of a treatment, and to communicate those wants and needs. There may be situations, like for example in body dysmorphia, where there is a disorder of the mind, and the practitioner deems that the patient does not have the ability to decide that they want a specific treatment. In this case, it is the practitioner’s duty of care not to perform a cosmetic procedure.

The GMC released guidelines around the delivery of cosmetic procedures in 2016, highlighting the consent is an absolute legal requirement of delivering procedures. Part of what this document emphasised was that this is a process, not a single event, and that practitioners must give their patients not only information, but also time – recommending a two week cooling off period before intervention.

Beneficence means that a doctor must do good for the patient, and in the field of aesthetic medicine this is certainly something that must be at the forefront. Most patients will approach an aesthetic practitioner because of issues with self-confidence or because they have negative feelings about their appearance. As long as these issues do not roam into the realm of body dysmorphia, practitioners are doing patients a lot of good for their self-esteem and, often, mental health when they assist with cosmetic interventions.

The issue of non-maleficence is very important in medical aesthetics. Ethical practitioners have a responsibility to manage patient expectations, as well as assess what is underlying a patient’s desire for a certain treatment and whether it will, in fact, be beneficial. A classic example of this is in the case of body dysmorphic disorder, as mentioned briefly above. One review has suggested that approximately 5-15% of patients seeking cosmetic treatments can suffer from this disorder. This group rarely experiences any improvement in their symptoms following treatment, and therefore a doctor who agrees to perform these procedures may be doing more harm than good.

Broadly then, in an aesthetic medical consultation, a good guide for ethical practice is to check that these four ethical principles are being fulfilled: that the patient is autonomously choosing their own treatments, that it will do them good and no harm, and that it is a just use of medical resources in allowing people to live better, happier lives.

References

Mercer N. Clinical risk in aesthetic surgery. Clinical Risk. 2009;15(6):215-7.

Department of Health. Review of the Regulation of Cosmetic Interventions. Department of Health,; 2013.

Fulton J, Caperton C, Weinkle S, Dewandre L. Filler injections with the blunt-tip microcannula. J Drugs Dermatol. 2012;11(9):1098-103.

Gillon R. Ethics needs principles--four can encompass the rest--and respect for autonomy should be "first among equals". J Med Ethics. 2003;29(5):307-12.

Health Education England. Qualification requirements for delivery of cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery. Health Education England; 2015.

Prendergast PM, Shiffman MA. Aesthetic medicine : art and techniques. Heidelberg ; New York: Springer; 2011. xiii, 629/

Sarwer DB, Crerand CE. Body dysmorphic disorder and appearance enhancing medical treatments. Body Image. 2008;5(1):50-8.