Do cosmetic procedures create ethical dilemmas?

Botox parties alarm dermatologic community

Following the disclosure that institutions as reputable as the Johns Hopkins Hospital in Baltimore have been holding Botox parties — social gatherings where alcohol is served and discount injections of botulinum toxin are administered — the American Academy of Dermatology (AAD) issued a warning to patients and a stern rebuke to providers who are too closely mixing business and pleasure.

"A casual social activity for the purpose of administering botulinum toxin, such as a Botox party, is an inappropriate and a potentially dangerous setting for performing medical procedures of any kind," said academy president Fred F. Castrow II, MD, in a statement about the practice. "Adding alcohol to the mix is a bad idea for a number of reasons, especially since bruising can be intensified."

One form of botulinum toxin, the substance that causes the disease botulism, has been approved by the Food and Drug Administration to treat some forms of wrinkles on skin.

"Botulinum toxin is a purified form of one of the most potent toxins in the world," the AAD statement noted. "In high doses, it can cause disease. When carefully injected by dermatologists and dermatologic surgeons in very low doses, it is a modern tool that can reduce the signs of aging."

However, when performed in unsafe settings, after hours, with food and drink served and, often by untrained medical professionals, Botox injections become much more risky, Castrow warns.

"Patient safety should come first and should not be taken lightly under any circumstances," the statement noted. "Because this is a quick method to treat wrinkles with no downtime, many patients may be compromising their safety by having these procedures in inappropriate settings."

Not just Botox

However, Botox parties are just the latest example of the medical specialty’s increasing reliance on promoting cosmetic procedures to increase reimbursement — a trend that raises serious questions about the providers’ medical ethics, some dermatologists say.

"Dermabrasion, laser procedures, the use of filler substances — these are not treating a disease process; they are just a means to improve profits," argues Eileen Ringel, MD, a dermatologist practicing in Waterville, ME, and an adjunct clinical professor at Dartmouth Medical School in Hanover, NH. "These procedures carry a significant risk of morbidity and are not in the patients’ best interest."

Following a trip to the annual AAD meeting in 1997, Ringel became alarmed at the increasing number of dermatologists flocking to demonstrations of cosmetic procedures and the comparatively low number attending disease-treatment sessions.

In a paper published in the Archives of Dermatol-ogy in 1998 and reprinted recently in the August 2002 issue of the watchdog group Public Citizen’s Health Letter, Ringel asked dermatologists to examine their motivations for performing cosmetic procedures to reduce the signs of aging and to consider the potential impact on society.

"What goals are we trying to achieve? Are these goals worthwhile? What is their impact on patients, on medicine, and on society?" she wrote. "A situation has developed in which there has been ample investigation into what physicians can do, but far less examination of what they should do."

Cosmetic dermatology treats the signs of aging skin as a disease process, offering treatments such as chemical peels, laser surgery, dermabrasion, injections of filler substances, and sometimes major surgical procedures to treat the illness that is aging skin.

The newer procedures have not been appropriately validated by clinical studies, and all of them have the potential to harm the patient by damaging the skin’s function as a barrier to external bacteria and toxins, Ringel tells Medical Ethics Advisor.

"As dermatologists, we are supposed to be supporting the maintenance of healthy skin, yet many of these procedures damage the skin," she notes.

The high cost of vanity

There also is the societal impact to consider. "Every time we perform one of these procedures, we justify it to the patient and to society," she says. "It is saying, Yes, you are getting older. You need to go and get all of these procedures done.’"

That is a terrible message for health care providers to convey, she claims. It violates the physician-patient relationship and the physician’s obligation to "do no harm," she says.

The primary motive for performing such procedures is money and not, as some would argue, improving patients’ self-esteem, Ringel adds. "There has been no argument for funding cosmetic procedures for poor people. This is solely a matter of increasing a physician’s revenue."

Publication of her paper in 1998 caused quite a stir at the time, but few dermatologists have shied away from cosmetic procedures as a result, she says.

In fact, the specialty has become even more focused on cosmetic services, she adds.

Recent press releases from the American Academy of Dermatology tout everything from the use of botulinum toxin injections to new ablative laser technologies to treat aging skin, with little mention of other services.

Ethics vs. values

The commonly performed procedures to treat the signs of aging have been demonstrated to be safe and effective, and they are procedures that people want to have, notes David E. Bank, MD, medical director of the Center for Dermatology, Cosmetic, and Laser Surgery in Mount Kisco, NY.

Many dermatologists began getting involved in cosmetic procedures in the late 1980s and early 1990s with the advent of products such Retin-A, Retinol and Rogaine, which promised to reduce various signs of aging on the skin and/or grow hair.

"There were all of the products on the market, making a variety of claims and promoted by a variety of people," Bank says. "People turned to dermatologists as the acknowledged experts on skin and how to care for it."

Dermatologists performing cosmetic procedures are catering to patients’ desires to look their best. But they are responding to society’s demands not dictating them.

"I don’t think people have cosmetic procedures simply because we are providing them," he says. "If they come to us, they can be confident that the procedures we perform are safe, effective, and will do what we say they will do."

To simply state that aging is a natural process and people should be satisfied with the way they naturally look is to make a personal value judgment and then impose it on another person, he adds.

"I don’t think that is about ethics so much as it is about values," he says. "It is interesting that here, there is all this debate over whether cosmetic procedures are right or wrong and whether we should alter our appearance. But in other countries — Brazil, for example — cosmetic procedures are performed all the time and no one bats an eye."

Cosmetic dermatologists do confront ethical dilemmas — they are just not over whether it is to perform cosmetic procedures in the first place, he adds.

"I think that the ethical issues involve ensuring patients understand what the procedure will and won’t do and that the provider has the skills to perform the procedure," Bank says.

If a provider is not skilled at a given procedure that a patient wants, he or she must be willing to refer the patient to someone else.

"You have to be particularly careful about patients who may have unrealistic expectations about what a given procedure can do," he notes. "If you have someone who is 60 and thinks they are going to look 20 again, that is not realistic, and they need to understand this."

Patients frequently come in requesting specific procedures that they’ve heard about through the media, but that don’t address their specific needs.

"They will come in an ask for a specific procedure, and it will turn out that that procedure won’t do what they are seeking to have done," Bank says.

It is essential that the physician have a discussion, guided by the patient, in which the patient relates what cosmetic problems he or she would like to improve, and the physician suggests procedures that might achieve those goals, he says.

It also is important to take an appropriate psychosocial history of the patient to determine whether cosmetic surgery or procedures to address physical problems is truly what they are looking for.

"A lot of times someone will come in and say they want a face lift because they want to look younger," he says. "But, if you talk to them a little while, you find out that maybe their marriage is in trouble, or they are having trouble with their kids, and they are focusing on this procedure to fix much deeper problems."

In these situations, it is important to be blunt if you perceive that the patient really is not prepared to undergo the requested procedure, he says.

"I tell people that liposuction will suck the fat out of your thighs — it won’t make you taller, it won’t save your marriage, and it won’t make your kids go to a good school," he states. "It will just take the fat out of your thighs."

He has heard of patients who want cosmetic surgery because they want to deceive employers or significant others about their true age, he notes. Though this could be considered unethical on the part of the patient, that is more of a moral issue than something the health care provider should feel compelled to judge, he feels.

Bank acknowledges that in talking about allocation of scarce health care dollars, no one is going to argue that cosmetic skin procedures are medically necessary or that they should be provided at public expense.

But that is true of a lot of procedures performed, both in dermatology and other specialties.

"If you talk about medical necessity in terms of preventing or treating conditions that are life-threatening or could cause serious illness, then many traditional dermatologic procedures would be excluded, most skin conditions — with the exception of cancer and some others — are not truly life- or health-threatening," he notes. That doesn’t mean that performing such procedures is inherently unethical, he argues.

"As long as you are performing procedures that are safe and effective, the patient does not have unrealistic expectations about the outcome, and you are not misrepresenting your skills as a provider, I think the decision about whether the procedures are appropriate should be up to the patient," he says.

Further reading

  • Ringel EW. The morality of cosmetic surgery for aging. Arch Dermatol 1998; 134:427-431.

Sources

  • David E. Bank, MD, The Center for Dermatology, Cosmetic, and Laser Surgery, 359 E. Main St., Suite 4G, Mount Kisco, NY 10549.
  • Eileen Ringel, MD, Department of Community and Family Medicine, Dartmouth University, One Rope Ferry Road, Hanover, NH 03755.