One of the early challenges of the Nuffield Council’s Working Party on cosmetic procedures has been to define what it is we should include in the concept of ‘cosmetic procedures’. Is it really possible to draw clear and consistent dividing lines between medical procedures undertaken for cosmetic purposes as opposed to rehabilitative/therapeutic purposes? And, at the less invasive end of the spectrum, is it possible to draw coherent distinctions between everyday beauty routines and procedures that span the beauty/clinical divide, such as chemical peels, laser treatments and skin-whitening treatments? Or are these lines inherently porous and fluctuating?
The fourth (and final) workshop of the Beauty Demands network, hosted last month at Manchester Metropolitan University, cast a fascinating light on these ‘boundary’ questions, as delegates explored the theme of ‘routine maintenance and exceptional procedures’, and demonstrated a range of complexities and contradictions. At first blush, procedures that can be described as 'routine' or as part of everyday beauty 'maintenance' must surely be insufficient to trouble even the most scrupulous ethicist - are they not, by definition, uncontroversial and even trivial? But as speakers demonstrated, this is often far from the case. The cumulative effort involved in procedures undertaken on a daily basis may be considerable - and ironically may be more demanding in terms of the investment of both time and money than more 'exceptional' procedures: contrast, for example, daily shaving with laser hair removal. Nor does the fact that a procedure is 'routine' make it risk-free: we heard of how the regular ‘sanding’ of nails for treatment with acrylics could over time cause lasting damage (not to mention the occupational health risks to those providing the treatments).
How often does a procedure need to be undertaken in order to be considered 'routine'? Daily procedures clearly fall into this category, but other treatments that are first seen as an occasional treat easily turn into a regular commitment. Staying with the nail bar example, acrylic nails need regular filling, and then replacing, with visits required every few weeks. What is considered 'routine’ is also a moving target. Influenced by shifting beauty norms, what we may feel routinely required to do, if only to meet an acceptable minimum with respect to expected appearance, may change with time: think, for example, of changing norms with respect to removing body hair. And what is seen as ‘routine’ (and by implication of little ethical concern) may relate not only to habitual practices by individuals, but also to wider social acceptability. Cosmetic dentistry is a ‘routine’ experience for many teenagers, but is there a risk that such 'normalisation' has made the entry threshold to what is a significantly invasive treatment too low and too casual? Research with women in the US and UK, exploring their experiences of cosmetic surgery, similarly reveals the subjective nature of what is considered routine: many women were eager to distinguish the 'normal' procedures they themselves were having from their perceptions of 'surgical junkies': women having 'too many' procedures, or perceived to be going 'too far'. Is there a risk that we simply use the terms 'routine' and 'exceptional' to justify our own choices and boundary lines?
There are, of course, important differences between major surgery and nail treatments, between Botox and facials, and so forth. The degree of invasiveness, and the risks involved, lie on a spectrum, and it is easy to distinguish between procedures that lie far apart on that spectrum. But the workshop discussion highlighted how that spectrum of risk is not the only issue at play here: when unease is expressed about 'going too far', for example, this concern relates not only to risk but to a less tangible sense that some motivations, or some desired outcomes, are suspect in a way that others are not. Perhaps this is the distinction that we are fumbling towards, however imprecisely, when we categorise some procedures as 'exceptional'?
Jumping forward a few weeks, many of the delegates at the workshop would have been pleased to see the launch of the new General Medical Council guidelines, setting clear professional standards for all doctors concerned with cosmetic practice, both surgical and non-surgical. These guidelines are concerned not only with ensuring that when doctors offer such procedures they are qualified to do so safely; they also emphasise professional responsibility in exploring whether an intervention is appropriate, and likely to deliver the patient's desired outcome. In other words, doctors are not simply 'technicians', whose job it is to use their skills in the way determined by their clients, but rather professionals with an overriding duty to consider the likelihood of 'overall benefit' to their patients before going ahead with a treatment.
These guidelines highlight a further disputed 'boundary' question in cosmetic procedures: that of who is (or should be) allowed to provide such procedures. Outside surgery, this is in the main an unregulated area in the UK: Health Education England has recently published comprehensive training requirements, setting out the skills and knowledge required of all practitioners providing specified procedures (regardless of their clinical background), but there are currently no reported plans to make these compulsory. The GMC guidelines hence provide a powerful steer to doctors as to what is expected of their cosmetic practice - but have no traction with others working in the field. While regulatory bodies governing other health professionals such as dentists and nurses are likely to provide similar updated guidance in due course, where does that leave the many practitioners providing non-surgical cosmetic procedures in beauty salons?
Just as the 'routine' and 'exceptional' distinctions wavered under the spotlight, however, perhaps some of our assumptions about the nature of professional behaviour also merit further exploration. The workshop delegate who described her experience of acrylic nail treatment also reported the painstaking way in which the salon staff kept client notes, and advised customers when it was necessary to let their nails 'take a break' to recover, even at the risk of losing the customer to another less scrupulous salon. Another reported on an initiative in the Netherlands to develop an ethical code for beauty salons, setting out clear professional expectations that in many cases parallel those expected of health professionals. Might one way forward be to map and promote high ethical standards of practice for all those providing cosmetic treatments, whether routine or exceptional, and regardless of the professional category of the practitioner?
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