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Ethics Of Aesthetics: Patient Management

Cosmetic procedures present a unique set of ethical issues that physicians should engage in their daily practice.
By: Richard G. Fried, MD, PhD


The practice of aesthetics offers clinicians a myriad of possibilities to build and maintain a successful practice, both clinically and financially. While not separate from the more traditional “medical” side of the practice of medicine, many aesthetic clinicians might agree that cosmetic procedures connote a different set of contingencies. Everything from how we talk to patients to how we collect reimbursement greatly differs from traditional clinical work. Therefore, it is incumbent upon physicians to recognize these contrasts and identify how to navigate the specific conditions that aesthetic practice entails.

Layered amid all the marketing, financial, and medical aspects of aesthetics is another major component that all clinicians must consider: Ethics. The reality is that physicians—by nature of their training—have knowledge, expertise, and a potentially manipulative power base (i.e. patients who are confused, vulnerable, or desperate in their life situations). As physicians, we must conduct our professional practices under the guiding premise that we are doing the right thing, for the right reason, and for the right patient. All of us must (and most do) adhere to the Hippocratic oath to do no harm. Therefore, it helps to think about each and every cosmetic patient encounter as culminating with the following question: For whom is the procedure being done, for what, and why?

Maintaining Identity

Despite some common stereotypes of the cosmetic branch of our profession, performing cosmetic procedures with financial benefit is not a “sin” as long as the patient is an appropriate cosmetic patient: one with realistic and attainable expectations, having no medical or psychiatric contraindications, and seeking the procedure for the right reasons. Fillers and botulinum toxin cannot “cure” marital infidelity, existential crises, or family dysfunction. However they can and have demonstrated measurable and meaningful improvements in the emotional and functional status of patients.

Maintaining the patient’s identity is one of the most important aspects of practicing aesthetics in an ethical manner. The goal of every well-performed cosmetic procedure is to produce a result that elicits reactions from others, such as: “You look great!” “Have you been away?” “Sleeping better?” “Doing yoga?” After a cosmetic procedure, it should be apparent that the patient looks better, fresher, well rested, a bit more youthful, perkier, more accepting, happier, less negative, less sad, less tired, less angry. It is important to convey these expected benefits to the patient in the initial consult. This is essential, because positive expectation and a good relationship with your patient is one of the most important aspects of attaining successful results.

When speaking with patients, tell them about your philosophy of “cosmetic conservatism.” Patients often are terrified that they will look like some caricature or “augmented freak” after treatment. Explain that your philosophy, goal, and practice technique are directed toward making them look younger, fresher, perkier, more energetic, and happier. Subtle changes to the oral commisures and cupids bow produced by precise filler placement can do all the above. These changes can make them look more youthful, and, as the anthropologists say, “more fertile,” which can elicit primordial arousal and attraction. However, it is important to emphasize that they will still look like themselves. I will often tell patients that there is no place for identity theft in appropriately chosen and performed cosmetic interventions. Our goal is simply to make them look like a younger, fresher “them.” It is important that patients understand this in order for you to earn their trust.

Personality Types to Avoid

While we can help our patients achieve their desired improvements, an important part of a sound, ethical practice of aesthetics is to know when to say no. Certain types of patients are simply not ideal candidates for cosmetic procedures. For example, those with Body Dysmorphic Disorder (BDD) often have excessive preoccupations with real or imagined cosmetic defects. Some warning signs for Body Dysmorphic Disorder include patients that have been to numerous previous clinicians with suboptimal outcomes and disappointments. Clinicians should on guard for patients who seem extremely concerned or overly preoccupied. Often BDD patients see the world in black and white. Moreover, BDD is associated with behaviors of drug abuse, excessive drinking or eating, sex addiction, and other forms of self-injurious behavior. Performing a procedure on a patient with BDD is almost guaranteed to be followed by patient dissatisfaction.

Another condition you may encounter in patients seeking aesthetic procedures is Obsessive Compulsive Disorder (OCD). These patients are often very detail-oriented, asking questions and dwelling at length on every detail. Providing written materials and Internet links for them to explore and dwell on in their own time may free you up to move on to another patient.

There are other general patient types that can pose obstacles to patient satisfaction. These include angry patients, individuals with unrealistic expectations, those enduring life crises, and patients who are desperate for intervention. There are also some patients (I call them “Or else...” patients) who expect their problems to be solved in one treatment “or else.” These patients tend to expect immediate and complete elimination of imperfections. They are often difficult to communicate with and hear only what they want to hear.

Psychological profiles aside, clinicians should also be wary of patients who are not ideal candidates on the basis of their clinical presentations. Patients with extensive skin laxity—i.e. infraorbital, cheeks, marionettes, etc.—clearly need surgical intervention. Thus, any improvements we can make will be so minimal or non-existent that all involved will be disappointed.

In general, expectation management is key in consulting with all patients about and performing cosmetic procedures. Importantly, setting expectations is different in the practice of aesthetics than from necessary medical procedures. In a rudimentary sense, skin imperfections associated with medical procedures are “easy” because the “suboptimal” outcomes are expected. If there is a scar, pigmentary alteration, telangiectatic mat, etc., the answer is quite easy. (“Mrs. Jones, you had cancer. We are lucky that this is all that there is to look at. You are cancer free… How lucky and blessed we are.”)

In contrast, if there is any suboptimal result or scar or pigmentary alteration after a cosmetic procedure, there is a very different set of rules and expectations. A patient might say, “You promised me that I would look better, younger, fresher…” Or, “This is terrible, unacceptable, horrible… How could this have happened… Why did you do this to me?!” The rules are quite different when performing procedures of necessity (cancer) versus elective (cosmetic). Suboptimal cosmetic outcomes result in “marriages” that continue until the “voluntary partner” is satisfied or until divorce occurs (with or without litigation involved).

Rejuvenation Beyond the Skin

Another major component of distinguishing the ethical side of practicing aesthetics is how clinicians are situated within a larger sphere of commercial interest. A sobering fact is that medispas and non-physicians are competing for the same clientele as us. Practicing sound, competent, and carefully contemplated aesthetics is therefore itself an ethical decision. In order to distinguish ourselves from less qualified and “hungry for procedures” clinicians, we need to foster an image of ourselves as the true experts of these procedures so that patients will respond.

It’s hard to know how much training and expertise is necessary/mandatory to increase the likelihood of optimal results and avoidance of complications and suboptimal results. It really comes down a question of how much training/experience is enough. Clinicians who perform cosmetic procedures ideally are always learning and growing based on experience and from dialogue with colleagues. It is imperative that each and every one of us get excellent and thorough training. We should always strive to better our techniques, cosmetic perspective, and approaches to beauty. If we are talented and achieve phenomenal results, we are always reading, seeking, observing, and experimenting with new and improved products and techniques.

And finally, we should convey and stress to patients that “nobody does it better.” Patients need to perceive and believe that they are in the “best of hands,” and only way for them to understand that is to emphasize it within and outside of our practices.

While a meticulous sense of ethics is important in maintaining a strong identity as a stellar clinician with a successful practice, we can never lose sight of our broader mission and why we practice aesthetics in the first place. Aesthetic clinicians should only perform on a patient what we would choose for ourselves and the people we love (unless we are talking about threatening illness with no other alternative). Be enthusiastic, confident, and compassionate. And most of all, promise from your heart what you can in reality deliver: Meaningful skin rejuvenation that can truly enhance the way patients feel, function, and embrace their world.