There is such a thing as an ethics of the beauty salon

Recent reports in the UK have raised worrying questions about the regulation of the beauty industry, whether it be the treatment of under-18s or the inadequate levels of care when removing moles and lesions. In 2016, Eline Bunnik wrote about how in the Netherlands these questions were already being taken seriously,  with the development of national ethical guidelines for beauticians. (This work was published as an article in Narrative Inquiry in Bioethics in 2018 https://muse.jhu.edu/article/712016)

Eline Bunnik (Erasmus MC, University Medical Centre Rotterdam) reflects on her work (with Frans Meulenberg & Inez de Beaufort) on a range of ethical issues related to beauty salons and beauticians in the Netherlands.

Worldwide, beauticians are progressively employing equipment and compounds that pervade more deeply into the skin, such as IPL/laser or chemical peelings. Present-day skin treatments aimed at hair removal, skin rejuvenation or therapeutic options for skin problems such as acne, may also expose clients to risks and irreversible outcomes. In the Netherlands, some beauty salon owners contract medical doctors to perform in-house cosmetic interventions, using botox and injectable fillers, sometimes to devastating effect (e.g. deformations, burn wounds). In the Netherlands over the past few years, ‘cosmetic errors’ have been highly publicized in national newspapers and daily television shows.

In response, in 2014, regulatory authorities announced measures to tighten governmental control over the beauty industry.. The Dutch Ministry of Health had considered the transferral of the use of IPL/laser technology (e.g. for hair removal) to a legal category of medical acts that only licensed physicians may undertake. The Dutch trade organization of beauticians, ANBOS, fearful for the livelihood of many among its constituents, has since attempted to demonstrate that the beauty industry has professionalized over the past few decades and generally adheres to high standards of quality and safety. Many beauticians have specialized in technical procedures such as laser-based hair removal, permanent make-up, dermabrasion and chemical peelings, and are becoming skilled and well-trained professionals. ANBOS has developed technical guidelines for what it calls ‘specialized treatments’ such as acne and depilation treatments, which involve potential risks for clients. It demands from its members that they will only perform specialized treatments if they are ‘competent and qualified’ and are in possession of a relevant and recognized diploma. Further, ANBOS handles complaints from clients across the Netherland, collects these in a central database and is connected to a board of arbitration on behalf of its members. If members wish to maintain their registration with ANBOS, they must attend regular training. The Dutch Minister of Health has repeatedly indicated that ANBOS is playing an important and trusted part in the self-regulation of the cosmetic sector in the Netherlands, and, so far, its members have been able to perform their activities in an unhindered fashion. As a part of its campaign, ANBOS has asked a research group at the Department of Medical Ethics and Philosophy of Medicine at Erasmus MC, University Medical Centre Rotterdam, to develop national ethical guidelines for professionals working in beauty salons.

First, the research group mapped ethical issues in the beauty salon on the basis of a literature review, fieldwork and, foremost, monthly meetings with a consultative group of key opinion leaders within beauty practices (n=8) with extensive hands-on experience in the field. The group agreed that since beauticians are making use of techniques and compounds that require specialized skills and may entail risks for clients, they are shouldering more and more responsibilities. Consequently, they are increasingly confronted with ethical dilemmas in the salon. When clients, for instance, have not proven compliant with explicit precautionary recommendations, such as staying out of the sun before a lased-based treatment, should beauticians proceed with the treatment or should they not? What if the client seems to understand the risks but insists on receiving the treatment? And what should beauticians do when regular clients appear to pursue impossible beauty ideals? Should they heed to or resist clients’ unrealistic wishes? Should they protect clients against themselves? And how should beauticians deal with dissatisfaction of clients? Beauticians are either running or employed within businesses, and must (help to) gain profits. At the same time, they want to - and must - provide high-quality, safe and effective services. Many beauticians perceive themselves as care providers, too, who are committed to the wellbeing of their clients. Can these interests be reconciled? Should beauticians, for instance, recommend expensive skin products to elderly clients of limited means? Should they sell a batch of skin creams that is nearing the expiry date? Can one be a businessman or woman and a caregiver at the same time? What expectations may one – realistically – entertain of beauty professionals? Our consultative group held that beauticians need not always and only act in the best interests of their clients, but should not act against the interests of their clients. They perceived themselves to be professionals, upholding a professional ethics, which hitherto had been tacit or implicit, but should, from now on, be part of basic beauticians’ training.

Other ethical issues include the unexpected implications of the easy and regular access beauticians may have to (part of) the skin surface of their regular clients. How should they handle incidental findings, such as suspect skin lesions, or signs of abuse? And what should they do when they suspect body dismorphic disorder or other psychiatric conditions? May beauticians treat children or minors, and if yes, on what conditions? Are beauticians bound by the principle of confidentiality? Would it be wrong to discuss clients with colleagues? What information should beauticians incorporate in their clients’ files? And must they obtain informed consent prior to the start of a treatment?
The research group has discussed these and other ethical issues with their consultative group and has formulated guidelines for their management. The draft guidelines have been corroborated through a survey among beauticians in the Netherlands (n > 300), by independent medical ethics experts and the board of ANBOS, have subsequently been finalized in the autumn of 2015, and will be launched soon. In the survey, we inquired into ethical issues encountered in everyday practice, ranging from informed consent to incidental findings, from treating children to responsibilities with regard to equipment or interns. The results of the survey will be reported in a scholarly journal

To our knowledge, ours is the first serious attempt to address ethical issues in the beauty salon from a medical-ethical perspective. The Netherlands appears to be unique in having developed national ethical guidelines for beauty professionals. At the workshop, I will present an inventory of ethical issues in the beauty salon, as well as some of the key findings from our survey and our most important recommendations.

Eline Bunnik is a postdoctoral researcher at the Department of Medical Ethics and Philosophy of Medicine at Erasmus MC, University Medical Centre Rotterdam, the Netherlands. Her research interests range from ethical issues in genomic testing and (non-invasive) prenatal screening to incidental findings in research settings and expanded access to investigational drugs. Eline is currently running multiple postdoctoral research projects and teaching ethics to medical students and doctors. With Inez de Beaufort, professor of medical ethics with a fascination for beauty, and Frans Meulenberg, director of the Dutch professional organization of dermatologists, she has developed ethical guidelines for beauticians in the Netherlands in collaboration with ANBOS, the Dutch trade association for beauticians, which will be launched shortly.