Having reflected on my own extensive and continuous training over the past two years within the field of aesthetics, it is clear to me that the reason that some practitioners practice with a lack of ethics is the lack of regulations within the field. Prior to entering the aesthetic field, I worked as a Registered General Nurse for over 14 years, and I was continuously governed and regulated by a statutory body. I ensured that I followed the code of conduct and acted in my patients' best interests at all times. I have transferred all of these attributes to my private aesthetic work, which is why I believe that I am an ethical clinician.
Unfortunately, due to the vast variety of practitioners across the UK, some of whom do not have a statutory body to report to, this is difficult to audit. Each individual complaint can only be investigated when a report of concern or complaint is made; this is then often reviewed by non-statutory registers, such as the Joint Council for Cosmetic Practitioners (JCCP) and Save Face.
We are all aware of the medic Vs non-medic conflict within the aesthetics sector. Although I do not support the use of cosmetic injectables by non-medics, I do not believe that just because we hold the title of a medical professional, we are automatically competent in carrying out these treatments. However, it does mean that if we are found to be practising unethically and unsafely, we are held accountable by law and have a duty of candour towards our patients.
Is that not what medical ethics is all about? Ensuring public safety? The JCCP have been directed by the government to review the aesthetics sector and have clearly stated that they advise the public to ensure they seek injectable aesthetic treatments from professionals registered on a statutory register only.
So lets look at ethical principles. The General Medical Council (GMC) ethical guidance for doctors in any area of practice states that one must adhere to the four ethical principles:
Let's investigate each of these principles in more detail, and determine what each one means in the scope of aesthetic practice.
Autonomy
Autonomy is one of the fundamental ethical principles in medicine. It is a term that describes the patient's ability and right to make an informed and un-coerced decision. Patients can only make a fully informed decision when they are presented with all the information of a proposed treatment.
This includes the benefits, risks (in general and for them specifically), complications, side effects, worst-case systemic response and final aesthetic outcome. The patient must be seen face to face and must receive both verbal and written information from the practitioner. This consists of including time to reflect upon, research and digest all information given to them. They can also obtain information themselves and must have a sufficient cooling off period (ideally 2 weeks) prior to any non-urgent cosmetic injectable treatment. I also encourage patients to discuss their decision with their friends and/or family prior to any treatment, as long as they feel comfortable or able to do so.
Autonomy is a principle that should be present throughout all medical health and practice with any procedure, whether it is a cosmetic injectable or any other. Healthcare professionals adhere to the Mental Capacity Act 2005 and, if they have concerns for the patient's capacity, the healthcare professional should lawfully address this with them and their GP, as long as consent is given and there are no life-threatening concerns.
However, a patient's capacity could be cause for concern by one practitioner but not another. This is where the difficulty occurs. To practice with autonomy is to safeguard the public and ensure that they are given the opportunity to be autonomous. Therefore, when a patient has no or little knowledge around the subject at hand, it is the practitioner's role to explain everything fully and fairly to enable the patient to be autonomous via education. This is our duty of care.
An overriding limitation to this principle is that we can only do our best, given the information presented by the patient. However, it is important to be mindful of the fact that it is impossible to anticipate the results of any given situation.
Beneficence
Beneficence means to always do what is in the best interests of the patient. However, one clinician's concept of what is good for the patient can vary greatly from another's, especially in aesthetic practice.
Beauty is in the eye of the beholder, and one person's idea of beauty may be different to another's. This is the reason we study the ageing process to an advanced level. As aesthetic practitioners, it is our job to restore lost volume and restore a more youthful appearance, rather than to drastically alter the way the patient looks. Causing a dramatic change to the patient's appearance may not be perceived as being of benefit to the patient.
Any treatment should only ever be carried out to improve a patient's appearance, mental wellbeing, self-esteem or confidence. This is a very contentious subject in the aesthetics sector, as the issue of whether a patient ‘needs’ treatment to improve their appearance is highly subjective and controversial. As practitioners, we may find that some patients physically do not require any treatment, but they mentally feel a lack of confidence in their appearance and are searching for something to make them feel better. In these cases, it is our duty of care to guide the patient, in this instance away from cosmetic injectables and toward a path that is more suited to their current mental health needs.
NICE Guidelines for Body Dysmorphic Disorder (BDD) and Obsessive Compulsive Disorder (OCD) (NICE, 2018) explain a care pathway that is recommended to support both practitioner and patient.
Non-maleficence
Non-maleficence means to do no harm. Harm comes in many forms—permanent, temporary, physical and psychological—and all carry severe consequences. A healthcare professional should always act as an advocate for the patient, especially in times of ill health, be it physical or mental. It is our duty of care to ensure that the patient has the best outcome possible. Assessing risk Vs benefit at all stages, especially during the consultation, is key to ensuring this. British Medical Journal (BMJ) Best Practice states that every health treatment has risks and benefits and a treatment that is right for one individual may not necessarily be right for their friend or neighbour (BMJ, 2019). Every individual has specific needs, and it is imperative that these are considered in full at the consultation stage to ensure that no harm is done to the patient.
Justice
Fred et al (2008) explained that justice is a very complex ethical principle within medicine, which covers a wide range of issues, from fair treatment to distribution of resources, respect for people's rights and respect for morally acceptable laws. All registered healthcare professionals are expected to adhere to policies, procedures, guidelines and their statutory agreements with their governing body. This ensures that healthcare professionals treat all of their patients with the same high standard of care.
Conclusion
With regards to aesthetics and cosmetic injectables, the above principles of ethical practice should always be adhered to, along with the principles of evidence-based science, research and practice.
The ethical principles discussed here are also discussed in the Nursing and Miwifery Council's The Code (2015), which encourages the prioritising of the patient and their specific needs above all else.
In summary, there is a distinct lack of legal regulation in aesthetic medicine which means that some practitioners are able to practice unethically. As healthcare professionals, it is our duty to ask ourselves whether we are practising ethically and following the guidance of our statutory bodies. We must challenge ourselves to review our guidelines and reflect on the service and treatments that we offer, and the way in which we conduct ourselves with our patients. Are your treatments evidence-based? Can you audit your practice? Can you show evidence of patient satisfaction and increased physical or mental positivity? Can you say that you have treated your patients within their best interests? These are the difficult questions that we must ask ourselves.