I have been around a long time in terms of medicine, aesthetics and life in general. I have watched the rise of cosmetic medicine from its humble beginnings to the burgeoning specialty that it is today. When I trained in 1990, the only injectable product available for cosmetic treatment was collagen produced from a specially bred herd of cows in the US. I remember the training day when only three doctors in Scotland were interested in having anything to do with something so ‘trivial’ and that was seen as less than worthy of a doctor's time. The Collagen Corporation started in 1975 in the US but is no longer active.
In a world where both men and women are living longer, patients want a face that reflects their internal feelings of youthfulness
The perception of the injectable aesthetic industry at that time was not very flattering, or indeed ethical, but was seen as a big money maker, with one journalist in the LA Times describing collagen for aesthetic use as ‘sticky glop’ and a ‘goo of natural proteins’ made from ‘cowhide’ and ‘the stuff’, sold to doctors, who then injected it under patients' skin to smooth wrinkles (Day, 1985). From the tone of this piece, it gives the distinct impression that collagen was seen as a fast money-maker. Indeed, it was nothing to be sniffed in the business world, as, by that time, only 10 years after the company was formed, the biomedical concern had made millions of dollars marketing implants to fill in facial lines and skin defects. Around a quarter of a million people in 25 countries were being injected and bring in 18 million dollars in revenue with a significant chunk of it coming in from the Beverley Hills doctors' offices. The perception of an unhealthy alliance between vanity and money-making was clearly taking shape. Collagen for cosmetic purposes may seem a bit obsolete these days, with all the different products and procedures that are widely available, but there were some things that were useful, and many are now recommending we should still do today. For example, there was a minimum of a 4-week cooling off period before patients proceeded to treatment. Admittedly, it was because of the possibility of allergy, but it also gave patients the time to assess information and come to a good decision for themselves. Often, this led to patients not coming back as they had changed their minds, or perhaps found the cost prohibitive. It was also important to let them know that the product was temporary, and if they liked the result, then this would be an ongoing financial commitment that they may or may not want to undertake. While some patients were lost, this stopped them making decisions that they perhaps felt they were being pressured into, as well as giving them time to actually go over all the new information they were presented with. Buyers regret was, and still is, always something to be aware of. Most patients were in their 40s and quite secretive about what procedure or treatment were having and had a desire to hold back time, rather than to look a lot younger or different. In short caution was the order of the day, and expectations as to what could be easily achieved were much more limited than they are now. Patients could be delighted with results, but never told anyone else that they had had anything done.
Ethical practice is more important than ever in a world of social media, where celebrities post details of their own cosmetic work
Practising in the age of social media
Fast forward to today's patients, who are often younger and may be influenced by the huge bombardment of cosmetic advertising and pressure from social and other media encouraging them to look a certain way or to copy the latest procedure that has been posted on social media by celebrities. This has not gone unnoticed by the Government, which commissioned the Keogh report in 2013 (Department of Health and Social Care, 2013), which made several recommendations about how aesthetic medicine should be regulated to keep patients safe. Some of the most important recommendations included the appointment of an ombudsman for the private cosmetic medicine sector, which was mainly aimed at plastic surgery, and the recommendation that dermal fillers should be prescription-only and carried out by properly trained medical professionals because of the inherent risks and possibility of permanent damage to patients. Now, while we are all professionals, how many people do we hear of who practice after a day or two of training? This raises the question of whether it is it ethical to do this. A quick search online provides approximately 11 000 available training courses ranging from 1–3 days long. Sadly, the Keogh report (2013) has not been implemented, although the Joint Council for Cosmetic Practitioners (JCCP) was set up in 2016 and has made valiant efforts to try and bring what has now become a free for all under its umbrella. Unfortunately, the JCCP is a voluntary register and needs, in my opinion, legislation to back it up, if it is to play a more meaningful role in regulating cosmetic practice. It has been very active in attempting to raise standards and continues to highlight significant areas of concern in the cosmetic industry. It also has a clear code of ethics that members on the register need to comply with.
» The prevalence in patients presenting at dermatology and cosmetic clinics ranges from 7% to 15%, with as many as 20% of patients presenting for rhinoplasty suffering from BDD «
The cowboys' days may be numbered
In 2017, the Nuffield Council on Bioethics ‘think tank’ also got involved in the ethical dilemmas of cosmetic practice, calling for legal age limits to be put in place (Nuffield Council on Bioethics, 2017). It recognised the anomalies in the law where there are legal age limits imposed on access to sunbeds and tattoos, but none in relation to cosmetic practices like dermal fillers. It also called for more responsibility to be shown by social media companies regarding the promotion of such procedures to young people and the pressure that they put on young people to conform to an ‘ideal’. The Nuffield Council on Bioethics also urged the Government to act on the Keogh report. The Scottish Government want to introduce legislation, and while this is welcomed as an attempt at regulating a ‘wild west’ of providers in some respects, it may have made things worse, as only doctors, dentists, nurses and midwives were included in the initial legislation. Regulating the already regulated did not seem fair when the unregulated could continue with impunity. With a consultation paper out at the moment that could and should be about to change and the cowboys' days may be numbered.
First, do no harm
Many female patients in their 40s and 50s, the new ‘ageless generation’ (Hardy, 2017), say they feel younger than their chronological age, are living longer and want a body, and particularly a face, that reflects this internal youth and not one that reminds them that time waits for no man or woman. In particular, women view ageing in a positive way, with fewer feeling anxious or depressed as they move into their 40s and 50s (Nolen-Hoeksema, 2010). No longer the hostage of ‘empty nest syndrome’, but positively enjoying their newfound freedom. If you look at the statistics, then more than 70% of those, male and female, seeking cosmetic enhancement are between the ages of 35 and 64, which is perhaps at odds with the often young-looking models in the popular press and on social media (UNC Aesthetic, Laser & Burn Center, 2013). While things have changed and are progressing in the aesthetic sector, some things have not changed and one of those is our duty as clinicians to our patients. The most quoted, and some say misquoted, line from the Hippocratic oath for doctors is: ‘First, do no harm’. It does not actually appear in the Hippocratic oath, but Florence Nightingale is documented as saying that a hospital should do the sick no harm. Our ethical responsibilities to our patients are still as important today as they always have been. Many might say that the people attending clinics for aesthetic treatment are not sick and, therefore, the word ‘patient’ is better replaced by ‘client’ or ‘customer’. For lay people, it may be fine to use the word ‘client’, but as clinicians, we cannot suddenly switch off our ethical or clinical responsibilities for convenience or profit—and we should not. Each clinical profession is bound by its own ethical code. If you are a clinician and someone comes to you for your expert advice and treatment in the aesthetic arena, then they are, by definition, a patient and you owe them a duty of care and confidentiality, just as you do in any other clinical field. Many years ago, I remember going for an interview with a large cosmetic company. I was told that I would ‘make a lot of money’, as they had staff trained to point out every line and wrinkle on a patient's face. At that point, I got up and left, making perhaps the biggest financial mistake but the best ethical decision of my aesthetic career. Once again, money seemed to be the main focus at the expense, literally, of the patient. That expense would not only be in monetary terms, but also in the patient's self-esteem and perhaps mental health. ‘First, do no harm’ appeared to be going out the window for profit (Poupard, 2012).
Consultations are an effective way to incorporate simple questionnaires that may pick up on the possibility of the patient's poor mental health
Ethical practice
Each profession has its own ethical code, but there is general agreement that there are some basic rights that patients have when they attend a professional for a clinical intervention or advice. However, there is some concern that the ethical codes are being tweaked, perhaps in pursuit of profit, particularly when it comes to plastic surgery, but it would not be too far a leap of faith the think the same applies for other aesthetic practitioners (Beauchamp and Childress, 2013). It is fairly straightforward to ask ourselves some questions to check our ethical and moral compass:
- Do we ensure the patient's autonomy?
- Does the patient make a choice of their own free will?
This would be without undue persuasion from the professional treating them. We must honestly ask ourselves if we put even the most subtle pressure on patients to have a cosmetic procedure. If we do, then it is unethical. When the patient asks me, as they often do, ‘what do you think I need done?’, my reply is always the same: ‘nothing’. I ask them what it is that they think they need done. It might lead to the same outcome, but it puts the patient clearly in charge. It is a better basis for an ethical discussion than a response that may disempower the patient. Do we act with the patient's best interests? This is known as beneficence, and it is important that we ask ourselves this question and answer it honestly. Can we honestly say that this is the case when the treatment we are providing has at its heart the survival of our businesses? If we cannot, then that is unethical. The principle that ‘above all, do no harm’, or non-maleficence is the one we all know best and that refers to not just physical harm, but psychological harm also.
Body dysmorphic disorder
Many patients waking through the door of aesthetic clinics often not only have physical issues and are on medication that practitioners need to know about, but quite a number have mental health issues as well. Around one in 50 members of the population suffer from body dysmorphic disorder (BDD), and it is thought to be a lot more common in patient's presenting at a cosmetic clinic (Kremer, 2017).
The prevalence in patients presenting at dermatology and cosmetic clinics ranges from 7% to 15%, with as many as 20% of patients presenting for rhinoplasty suffering from BDD (Veale et al, 2003; Nachshoni and Kotler, 2007). On average, women spend over 40 minutes every day looking at their reflections and men spend even longer (Torres, 2012; Betta Living, 2014). This may seem excessive; however, most people with BDD will spend well over an hour, and sometimes as long as 8 hours, obsessing about their appearance. They also post a lot more selfies than the average person. I am as guilty of taking selfies as the next person but take refuge in the fact that the modern cult of the selfie is not all that modern at all, and the human race has been looking at its own reflection since time immemorial. Early mirrors found in Anatolia in Turkey lay testament to that, as do the multiple self-portraits that famous artists painted. Take Freida Kahlo, who produced some 55 self-portraits, often depicting her physical and emotional pain, which is maybe preferable to the inane smiles of today—or maybe not (Velimirović, 2018). How many hours did that portrait take, and did she have BDD? We will never know, but fortunately, since BDD is included in the Diagnostic and statistical manual of mental disorders (American Psychiatric Association, 2013), we now have very clear-cut guidance in what to look for and how to screen for it. We might not always pick up on it, but we should at least try be seen to be trying and document it. A simple BDD questionnaire, and there are several available, included in the consultation is useful not only as a screening tool but also as a way to keep you and your patient safe by promoting good practice. Pay attention to your inner voice or gut instinct when seeing a patient. Things that make me uneasy are the patient who has never been satisfied with any treatments in the past, the patient who has an overtreated appearance while still looking for treatment, flaws pointed out that are virtually impossible to see, neurodermatitis and obsessive-compulsive symptoms (as obsessive-compulsive disorder frequently co-exists with BDD). If you do suspect BDD, then you should give the patient-appropriate advice and it is always handy to have some local mental health service contact numbers in your clinic that you can pass on. Offering to see them at some point in the future might also be appropriate, as refusing to treat the BDD patient at all can also cause issues, as they may feel that they will never be ‘normal’, and may just take to treating themselves Healey, 2016). Therein lies another ethical dilemma. With the general public being more open about mental health issues and more information being available about mental health, it is not inconceivable that today's overtreated patient becomes tomorrow's litigation.
Conclusion
Like most clinicians, I am keen that the long overdue legislation to regulate aesthetic medicine catches up with the rapid expansion of the specialty. The lack of appropriate training and qualifications held by of people carrying out procedures is extremely concerning, and we need to keep bringing that to the attention of the legislators and public. We can only be taken seriously if we stick to the ethical guidelines that we all agreed to uphold and apply them to our cosmetic practice. If we first, do no harm, then both our patients and we, ourselves, are more likely to stay safe.