From botox to facelifts - should professionals say yes? Further reflections on the second Beauty Demands workshop from Katharine Wright

Katharine Wright

This is the second of two blog posts by Katharine Wright, Assistant Director of the Nuffield Council on Bioethics. The blog was written following the second Beauty Demands workshop. The third workshop will take place 14-15 October in Birmingham and will focus on the globalisation of beauty. The deadline for abstracts is 16 July at 4pm. 

As the demand for cosmetic procedures continues, what are the responsibilities of health professionals and scientists in developing, providing and actively promoting invasive non-reconstructive procedures that aim to enhance or ‘normalise’ appearance?

This was one of the topics we explored at the second workshop of the AHRC-funded Beauty Demands project on ‘Professionals, practitioners and beauty norms’ bringing together academic experts on body image and fashion, psychologists, philosophers, lawyers, surgeons and GPs to debate the role of professionals in responding to the changing requirements of ‘beauty’ (see my first blog, Body image, beauty myths and cosmetic procedures).

While there are powerful arguments in support of the claim that what people (certainly adults) choose to do with respect to their own appearance is nobody else’s business, there is also a strong public interest in how those working in the health sector exercise their professional responsibilities, given the trust-based nature of the field in which they work.

By developing new procedures, by actively advertising and marketing them on a consumer basis, and then offering them in a medical or quasi-medical environment, professionals take on an active role in encouraging the use of invasive procedures for cosmetic purposes. The fact that they are trusted as health professionals – think of the trust-based assumptions associated with the terminology of a ‘medi-spa’ – creates further dilemmas. Are those seeking procedures ‘patients’ or ‘consumers’? Are they requesting, or consenting to, procedures?

We heard the shocking statistic that only 4% of cosmetic clinics (out of the third who took the trouble to report their professional practices at all) offered prospective patients access to professional support from a clinical psychologist – despite the critical role of psychologists in helping people identify the extent to which a cosmetic procedure is likely to achieve their desired ends. Surely any ‘consent’ process worth its name should ensure some matching up of the likely outcomes of the procedure and the patient’s hopes in undertaking it?

Perversely, the role of regulation in the field sends similarly conflicting messages – the need for regulation is clear, given the obvious dangers posed by unqualified practitioners or unsafe equipment, but the fact that an area of activity is regulated may be seen as implicit public policy endorsement, and hence automatically ‘good’, ‘normal’ or ‘safe’.

The surgeons present at the meeting emphasised how important it is for surgeons to know when to say ‘no’ to a prospective patient/consumer – which brings up questions not only of professional responsibility and accountability, but also the training necessary to develop that knowledge and confidence. If cosmetic procedures are seen primarily as a matter for the private sector, outside the Royal College training programmes operating through the NHS, doctors working in this field will not have had the experience of sitting in a more senior colleague’s office and hearing him or her say ‘no’.

We heard much frustration on the part of doctors and others in this field that the numerous reviews and attempts over the years to improve professional practice appear to have made little progress – those committed to improving practice feel continually let down both by the failure of governments to act and by the ‘cowboy’ element in their own profession.

Yet there is still significant momentum for improvement – the GMC issued new guidance for consultation a few days after our workshop, and we heard of highly pragmatic work emerging from the University of the West of England, such as the creation of a one-minute screening tool for cosmetic surgery, to maximise the chance that clinics will be able to ‘screen out’ those whose desires and expectations of surgery are unlikely to be met. Surgeons committed to improving practice are working at both national and local levels to remove barriers to improved training, and to find levers for enforcing higher standards, for example by making them an essential requirement to continue obtaining professional insurance.

What does this leave for the Nuffield Council on Bioethics to do? A concept that emerged over and again during the workshop was that of the challenges in drawing ‘ethical boundaries’ – between what is always acceptable or always unacceptable; between what might be acceptable for some people or groups of people or not others; indeed what is ‘cosmetic’ in the first place since the distinctions between cosmetic and reconstructive procedures are far from clear-cut; and who is a ‘professional’ when not all invasive procedures are provided by doctors or nurses.

Similar ethical boundary challenges arise in the way professionals conceptualise their actions: does operating on a ‘normal healthy body’ respond to a patient’s autonomously chosen desires, or contribute to a vicious circle of bodily dissatisfaction? How do we make these distinctions, and indeed whose job is it to make them? These are the kinds of issues that the Council will be exploring over the next year in its project on cosmetic procedures