Regulation and cosmetic procedures: counselling caution

Harry Cayton, Chief Executive of the Professional Standards Authority, gave an address at the launch of Council’s report, Cosmetic procedures: ethical issues, on 22 June 2017. This blog is based on that presentation.

I was struck by this statement in the report: ‘Cosmetic procedures are a physical intervention whose hoped for benefits are primarily psychological.’ It is that gap between the action and its consequences into which the ethical dilemmas of cosmetic practice fall. And it is that gap which this report so admirably attempts to address.

I’m sure you will understand that it is no criticism that I say ‘attempts’ to address. Like most of the issues to which the Council bends its many minds, there is no ethical certainty or obvious right and wrong. Indeed if it were obvious what was right or wrong in cosmetic practice we wouldn’t need a report of such careful analysis and thoughtful guidance.

The historical principle of clinical ethics is, ‘First do no harm’. Unnecessary medical interventions are by definition harm so it is clear to see why non-reconstructive cosmetic procedures raise particular ethical dilemmas.

If the desire to appear ‘normal’ or to be ‘beautiful’ is in a particular individual a necessity, then this is clinical practice in a complex social and cultural domain, rather than a medical one.If cosmetic procedures are not a necessary clinical intervention but a matter of consumer choice, then it is quite hard to see this as medicine at all, but rather as the application of medical and other techniques in a commercial industry and thus subject to the ethics of the marketplace.

But if we take a broader view of clinical practice and call it healing, or therapy or well-being, a wider set of values may apply.

One of the values of this report is that it looks in a clear-sighted way at the different ways in which we can interpret the cultural meaning of body-changing interventions, be they to eliminate or exaggerate distance from the norm.

There are two particular aspects of the report that I commented on in my speech. The first was the subject of Chapter Eight, which addresses, amongst other things, the important issue of children and young people. The second was the subject of Chapter Four, which covers the regulation of cosmetic procedures.

In relation to the first, I strongly endorse the recommendation that cosmetic procedures should not be available to children and young people. The report rightly addresses the issue of why they might seek changes to their appearance. If we are to be positive about personal appearance and identity – anxiety about which is of course a normal feature of adolescence – we require the right attitudes and action by families, schools, the advertising industry and the media.

Bringing about such changes, as we can see from the challenge of childhood obesity, is far from easy when there is such inequality of arms between the parties.

In relation to the second, regulation is about the prevention of harms. Sometimes it is thought, to be about the reduction of risks, but risk is only the likelihood of harm happening. ‘What harms are we trying to prevent?’ is a better regulatory question than ‘What risks are we trying to mitigate?’

The report places great hope in the power of regulation. Let me counsel caution. Regulation is a blunt instrument. And the regulation of businesses – of commercial interests – which is what we are talking about here – is different from the regulation of healthcare. The incentives to work well or badly, to risk harm for personal gain, to sell products regardless of their benefit to consumers are different when the primary objective is to make money.

Nor is regulation a single activity. It is for instance much easier to determine the effect of regulating products than of regulating people. The regulation of products is determinative; the regulation of people is not. And in any event the main providers of cosmetic procedures – doctors and nurses – are already regulated. And yet we remain concerned about the ethics of cosmetic practice.

I also believe that over-regulation disempowers the consumer. We should have to think for ourselves, to find out, to make informed choices.

Rather than relying on regulation, we should make the providers of cosmetic services legally and financially accountable for any harm they do; transparency, accountability and redress are useful tools in the control of commercial interests.

Finally I should like on behalf of all of us who care about these issues, to thank the working Party, under its chair Professor Edwards and the Council’s Executive for their usual brilliant distillation of the complex into the comprehensible. If even a small proportion of the recommendations are taken forward there will be greater accountability by providers, greater clarity for their clients, and greater public protection for us all.

Harry Cayton Chaired the Expert Group on the Regulation of Cosmetic Surgery, the report of which to the Chief Medical Officer was published in 2005.The Joint Council for Cosmetic Practitioners is currently applying for the Professional Standard Authority’s Accredited Registers quality mark – the new voluntary register of practitioners qualified to provide non-surgical cosmetic procedures.