This article discusses the concepts of ethics, accountability, transparency, integrity and professionalism in aesthetic practice. It will discuss some practices and behaviours that form the basis of ethical behaviour, by putting special emphasis on accountability, transparency, integrity and professionalism, as well as exploring some of the issues that compromise ethics in aesthetic practice.
Although the aforementioned concepts are interrelated, and attempts can be made to define each of them independently, when examined as a whole, it is evident there are no clear-cut boundaries.
This lack of definition may positively or negatively impact on others, which implies that all medically-qualified aesthetic practitioners should possess the knowledge and attributes to put ethical principles into practice.
Ethics
Ethics deal with the character, conduct and morals of human beings. The study of ethics deals with good or bad, right or wrong behaviour; it evaluates conduct against some absolute criteria and puts negative or positive values on it (Committee on Standards in Public Life, 2014). Ethics can also be defined as the basic principles of the action and rules of good conduct. These criteria can be in writing, such as legislation or circulars, or merely the interpretation by an individual of what is acceptable and what is not.
The Nursing and Midwifery Council (NMC, 2018) adheres to the notion that ethics are the ‘gold standard’, as in ‘the standards which guide the behaviours and actions of nurses and midwives working with the public’, and aims to uphold ethical values and principles throughout nursing practice.
Such values and principles within an aesthetic setting could include efficiency, professional discipline, dignity, equity, impartiality, fairness, public-spiritedness and courtesy in the discharge of duties.
Accountability
Although accountability is widely considered to be a positive thing, the concept is highly abstract and is often applied in a very general way (Care Act, 2014). Within aesthetic practice, accountability concerns the processes by which those who exercise power, whether as organisations, groups of professionals or individual practitioners, must be able to show that they discharged their duties properly and to the best of their ability.
According to the NMC (2018), accountability means being answerable for the decisions made in the course of one's professional practice. Nurses and midwives are accountable both legally and professionally for their practice, that is, for the decisions they make and the consequences of those decisions (NMC, 2018). Accountability is therefore an ethical virtue, since ethics concern principles and rules that govern the moral value of people's behaviour. Therefore it stands to reason that a sound ethical platform within medical aesthetic practice is crucial to enhancing accountability, and vice-versa (Royal College of Nursing (RCN), 2015).
Transparency
Generally, ‘transparency’ implies openness, communication and accountability. Literally speaking, it refers to a ‘transparent’ object, which is one that can be seen through. With regard to aesthetic practice, it means that practitioners should be as open as possible about all the decisions and actions they make. They should give reasons for their decisions and restrict information only when the wider public interest demands it (Kaplan, 2018). Transparency, therefore, promotes accountability and provides information for patients about what their practitioners are doing.
Integrity
Integrity is one of the most important and most often cited of virtue terms. The concept of integrity has to do with perceived consistency of actions, values, methods, measures, principles, expectations and outcome. When used as a virtue term, ‘integrity’ refers to the quality of a person's character. Some people see integrity as the quality of having a sense of honesty and truthfulness with regard to the motivations for one's actions. Persons of integrity do not just act consistently, they also stand for something and use their best judgement when making decision.
The idea of integrity as personal honesty, that is, acting according to one's beliefs and values at all times, is crucial to professional aesthetic practitioners (Healthcare Compliance Pros, 2018). By mere utterance of the word ‘integrity’, the ‘wholeness’ or ‘intactness’ of a moral stance or attitude can be emphasised.
According to Halfon (1989), ‘Persons of integrity impose these restrictions on themselves since they are concerned, not simply with taking any moral position, but with pursuing a commitment to do what is best’. This view is further supported by Carter (1996) who surmised that integrity requires three steps:
Professionalism
Within the context of this article, professionalism is defined as the overarching values that encompass all other values guiding aesthetic practice. These values include loyalty, neutrality, transparency, diligence, punctuality, effectiveness, impartiality and other values that may be specific to aesthetic practice.
Professionalism within aesthetic practice entails that people who work within this field of practice need to be working as one; they should have shared values and should be trained in basic skills to professionally carry out their official duties efficiently and safely in accordance with NMC (2018) guidance.
The rationale underpinning professionalism is that practitioners should be neutral, impartial, fair, competent and serve the public interest in carrying out their duties. They should be fairly remunerated and adequately trained to perform their work.
Kirk (2007) asserted that professionalism is an adherence to a set of normative and behavioural expectations, which are usually embodied in a code of ethics, not unlike those of the NMC or specialist aesthetic practitioner groups, such as the British Association of Cosmetic Nurses (BACN, 2019).
Duty of care
The NMC Code (2018) is clear that it requires that individuals be treated with respect, dignity and compassion. The Code (NMC, 2018) further underpins the need for all those on the professional register to ensure that they not only prioritise people, but also that they practise effectively, using the best available evidence. The Code also states that nurses are accountable for their decisions, be that treatment decisions they undertake themselves or those tasks and duties they choose to delegate to others. Nurses and midwives are further reminded of the requirement to preserve safety by recognising and working within the limits of their individual competencies and to promote professionalism and trust at all times.
Regrettably, it is sometimes the case that NMC registrants working within the highly unregulated field of aesthetic practice and non-surgical medicine fall foul of their professional code of conduct. This might be by working beyond their scope of competency and practice, by illegally advertising and incentivising prescription only medicines for financial gain, or not being open and candid with service users about all aspects of their care and the treatments offered, even when adverse events may occur. In some instances, the drive to maximise profit may lead to poor decision-making and a failure to look at the available evidence when selecting products, which may lead to the use of products without robust clinical safety trials or quality assurance.
Practices undermining ethical practice
The practices and behaviours that undermine ethical practice in aesthetics are many, but include:
Broadly defined, corruption is the abuse of entrusted power for personal gain (Xizi, 2016). Corruption is a serious unethical practice that undermines the trust and confidence of patients and the wider public. This confidence can only be reclaimed by establishing a reputation of integrity.
Corruption has multiple roots, but, generally, it can be attributed to the poor design of an institution or area of practice and unclear, complex and frequently-changing laws and regulations. When laws are contradictory or require heavy interpretation—as is the case with aesthetic practice in the UK—practitioners may not be clear of their obligations towards the public and, therefore, may fall foul of the law.
Furthermore, within the field of aesthetic practice, the discretionary power of individual practitioners is amplified, increasing the risk that they might make arbitrary, self-serving decisions, with little robust intervention to prevent them from doing so.
Conflicts of interest
A conflict of interest may arise when the personal interest of an individual is in conflict with his/her official position. In some cases, this could mean that the private interest of an aesthetic practitioner might lead them to discharge their duties in ways that may not be in the best interest of the patient or organisation. According to Williams (1985), conflict of interest denotes ‘a situation in which an individual has a private financial interest sufficient to influence, or appear to influence, the exercise of his/her public duties and responsibilities’.
A primary reason for concern about conflicts of interest is that they reduce public trust and confidence in the integrity and impartiality of practitioners and organisations. In this respect, the appearance of a conflict of interest can be damaging and may lead to divided loyalty, which, in its most serious form, could result in corruption.
One example of a potential conflict of interest situation within aesthetic practice is when a practitioner suggests a particular product range exclusively, in return for participation in educational forums and conference attendance, or gives endorsement to products or machines for which they receive financial gain.
Guidance
Inadequate or inappropriate policies and practice guidance can result in malpractice, which threaten professionalism, ethical behaviours and transparency. By failing to state and enforce the principles of ethics and integrity within the field of aesthetics, practitioners are void of ethical and integrity direction (Greiner and Knebel, 2003).
Although nurses and midwives are bound by the NMC code (2018), a lack of a specific code of ethics to guide and enforce standards and professionalism within the specialism of aesthetics may lead to a lack of accountability. In addition, this allows the whole system to be vulnerable to malpractice and corruption.
Furthermore, a failure to outline and enforce limits on personal, political or financial influences may allow these to affect safeguarding transparency within our practice or the organisations we are employed by.
As well as providing guidance and templates, the organisation Save Face assesses each and every practitioner (and the premises from which they operate) against a rigorous set of standards (Save Face, 2019).
The BACN code stipulates that its members must provide nursing care that is in accordance with the NMC code (2018), as well as stating that members must maintain professional registration to practise through continued professional development and evidence-based lifelong learning.
As well as offering peer support and the opportunity to take part in nurse-led conferences and meetings, the BACN encourages all practitioners to be accountable for their own actions and the care they provide. Above all, the organisation places an emphasis on putting patients first, without commercial bias or external influences.
Responsible marketing
In 2013, the Department of Health and Social Care (DHSC) published a paper that discussed a project to determine regulation of cosmetic interventions and the impact of advertising and targeted media in magazines and on social media platforms, such as Twitter and Facebook (DHSC, 2013). The research focused on groups of teenage girls in the UK and assessed their perceived motivations to undergo cosmetic interventions.
The research concluded that young people under 18 years old were vulnerable to suggestions of cosmetic interventions. It also found that external networks of people (friends and family members) who had undergone successful procedures exerted a powerful influence on both adults and teenagers alike to consider undergoing a cosmetic procedure. The impact of celebrity culture cannot be underestimated and, with more and more aesthetic practitioners vying for a more public persona, the lure of obtaining celebrity endorsement can be difficult to resist. But if we are to protect our patients and work ethically and safely, we must resist these temptations.
The promotion of natural enhancement features heavily in some of the more recent publicity from major aesthetic suppliers. With the lack of regulation here in the UK and the ever-increasing number of cheap imported fillers and products, it is a step in the right direction, but it remains to be seen whether these measures will be enough to turn the tide after a decade of plumping lips, cheeks and freezing foreheads.
Nurses working within the field of aesthetic medicine carry as much responsibility as those working within the NHS or other healthcare settings, and should be willing to promote and protect the rights of patients. This means that aesthetic nurses must ensure that they adhere to responsible marketing and advertising standards, which means being clear, factual, truthful and steering clear of promotional tactics. Furthermore, all patients should be given a cooling off period, so that they have ample time to consider the treatment information, enabling them to make an informed decision without pressure or coercion.
Conclusion
It is clear that, in this developing area of practice, we still have a long way to go in terms of raising standards. On social media forums, there is the constant endorsement that the public choose only medically-qualified practitioners. Aesthetic nurses must unite and abide by our own professional code (NMC, 2018) by sourcing the best quality products and understanding the research base underpinning their use; developing our assessment and consulting skills; ensuring safety; becoming accountable for our actions in terms of treatments and prescribing; working within our professional competencies and striving for both peer and external validation of our work.
As registered nurses, we have an advantage over our non-medical colleagues and competitors. Perhaps the way forward is to get our own house in order first and raise the bar, then everyone, particularly the public, can benefit.