Ethical Issues — Cosmetic & Laser Treatments

Marylyn A. Hagerty, PhD, FNP – BC

Author's Note: The opinions expressed in this article are solely those of the author.

The Derm NurseAesthetic and cosmetic medicine is one of the fastest growing segments of medicine today. Non-invasive cosmetic procedures are on the rise. These procedures include neurotoxins, dermal fillers, laser resurfacing, laser removal of hair and tattoos, radiofrequency for skin tightening and more. Injections and lasers used for weight reduction are also an example of a non-invasive cosmetic procedure. As this specialty grows, it becomes even more important to look at the ethical principles associated with this practice.

Clients seeking aesthetic and cosmetic procedures are often influenced by misleading advertisements. This raises questions regarding the ethical principle of autonomy. Autonomy is the respect for the patient’s right to self-governance, choice for care and the right to accept or refuse treatment.1 Autonomy does not exist alone; it is influenced by other ethical principles including beneficence, non-maleficence and justice. The principle of autonomy dictates that the client has the right to make his or her own decision as to what procedure he or she want to have. Therefore, the client’s right to an informed consent must be respected. For informed consent to take place, however, the patient must be given the correct information as to the realistic expectations, the risks involved and the alternative options available to the procedure that has been chosen.

Due to misleading media advertisements, clients will often come to the first consultation thinking they know exactly what procedure they want to have. In reality, it may not give them the optimal results. The advertised procedure may not be correct for their personal skin type or their age, or misleading photographs may promise unrealistic results. The patient may be in an emotional state from an unhappy relationship, facing a career crisis or have body dysmorphic disorder. These individuals will have unrealistic expectations about the capacity of a non-surgical procedure, expectations fed by the unrealistic results displayed in industry photos and advertisements. They look at the procedure as the way to repair a damaged marriage, for that job promotion or for emotional security: “If I just get this procedure, I will be beautiful and happy.” An example is a dark-skinned client coming in and requesting IPL hair removal. For a patient with Fitzpatrick skin type VI, this treatment would be contraindicated. It is up to the practitioner to inform the client why the procedure would put the client at high risk for complications and would not be beneficial. If the client insists, the practitioner must remain ethically bound to refuse even if it means costing them a sale.

The principle of beneficence requires the practitioner to act in the client’s “best interest.” It is important for the practitioner to assess the risks versus the benefits of the procedure, the motivation of the client for having the procedure and how it will affect quality of life.

The principle of non-maleficence requires the practitioner to do no harm and to act in the client’s best interest. The practitioner should be reluctant to perform a procedure on a client who has unrealistic expectations. The practitioner must also, again, discuss the possible side effects of the procedure, the post-procedure treatments and the follow-up procedures that may be required. At this point the practitioner may suggest alternative procedures and treatments that may be more beneficial for the client or refer the client to another medical professional that specializes in other treatments that would yield the desired result. An example would be a patient desiring skin tightening following significant weight loss. This client would be better served by the services of a plastic surgeon rather than attempting to tighten large amounts of redundant tissue with radiofrequency tightening of the skin.

The principle of justice requires the practitioner to be respectful of the client’s wishes, to listen to the client and to educate the client about what to expect from the desired procedure, not just to look at what the practitioner stands to gain financially from doing the procedure.

Ethical Conflicts

Ethical conflicts arise when a practitioner struggles with beneficence vs. economic interest. An example of this would be a client who arrives in a clinic on Wednesday who is getting married on Saturday and desires dermal filler in her cheeks and nasolabial folds. The practitioner knows the risk of potential bruising, localized temporary edema or the possibility of an unanticipated reaction to the filler for lidocaine, but instead looks at the possibility of a sale rather than what is in the best interest of the client.

Underestimation of risk by the provider occurs when the provider is not properly trained or does not have the experience to perform the procedure. Inadequately trained practitioners may not only misuse the equipment but also are ill informed of the capacity of the equipment or complications that may result. But these very practitioners are still responsible for obtaining informed consent from the client. Unfortunately, stories are common of the one-hour meeting with the sales consultant and, subsequently, a practitioner who owns the piece of equipment who is open for business and treating patients but does not really know how to handle any subsequent complications.

Another conflict occurs when the practitioner is over servicing due to the high cost of equipment. The need to make the equipment payment and the potential for high monetary gain causes this conflict. This occurs in some practices where consultants are commissioned-based and looking to cover overhead and for higher profit margins.

Over emphasis of the benefits of certain procedures, especially at public talks, and medical advertising that plays on the insecurities associated with the aging process create another conflict. The media creates a misleading impression that there are certain procedures that will stop the aging process; in reality, there are no such procedures. There is no one treatment or procedure that will work for everyone; yet, when you watch TV or pick up an article, it is being promoted as the next best thing. The problem with this is that very few products or procedures work universally for everyone, just like the number of treatments needed varies from person to person. Once again, it is prudent for the practitioner to explain to the client that each person, each case, is unique, and the treatments must be administered as such. Results will vary and depend on time and financial commitments of both the client and the practitioner. Maximum benefit, or return on the investment of the client’s dollars and time, must remain foremost in the ethical practitioner’s treatment plan.

Industry interest in loaning or renting equipment can create conflict. Today, the practitioner does not need to own the equipment. The practitioner can rent the equipment by the hour or day. Companies will even send a technician to run the equipment for the practitioner; the practitioner doesn’t even need to be in the room. So how does the practitioner do the consult and explain the expectations and side effects when they have never used the equipment? It is imperative that the practitioner has been trained and understands the physiology of the laser or piece of equipment being used. Perhaps it would be beneficial to require evidence of training or certification on equipment to be rented, no matter what license the practitioner holds, to help reduce the risk of such knowledge gaps when consulting a client.

Our industry is rapidly evolving and ever changing, and society is very much in the pursuit of what is considered “beauty.” It remains to be seen, however, where this industry will go in the next few years. One thing is certain: We must continue to operate in an ethically responsible manner and provide the best care possible to our clients.

The Dermatology Nurses’ Association (DNA) has recently approved two positions relevant to this topic: The Nurse’s Role in the Use of Laser, Light and Energy Emitting Devices and The Nurse’s Role in the Provision of Cosmetic Services. For more information, please click here.

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