Technology, public demand
Growing patient interest in the power of cosmetic interventions has led to an exponential market demand for fillers, lasers and injections of botulinum toxin. Almost every year there appear to be dramatic appearances of either new lasers or fillers. Food and Drug Administration (FDA) trials currently are under way to evaluate botulinum toxins that may compete with Botox (Allergan).New creams with a variety of growth factors are said to represent the Fountain of Youth. This explosive phenomenon may simply coincide with advances in the science of anti-aging. Alternatively, it all might be attributed to America's obsession with celebrity, youth and beauty.
Regardless of its etiology, cosmetic dermatology has gained a foothold in American medicine and culture. Its procedures are now an integral part of dermatologic practice. In fact, procedural dermatology is a newly recognized fellowship program that is now accepted by all of mainstream medicine.
At the core of this post-dermatology residency training is not only Mohs skin cancer surgery, but also the myriad aspects of today's cosmetic dermatology. Because it is largely, if not exclusively, a fee-for-service business, cosmetic dermatology has become one of medicine's few remaining golden eggs. As is the nature of all occupations, where money goes, ethical questions are expected to follow.
Perhaps there is no field in medicine such as cosmetic dermatology where scientific advances appear to run light-years ahead of ethical analyses of those changes. This may leave society wondering if we should do all the things we can do.
Such questions have often been asked about plastic surgery. Some have now begun to ask those very same questions about cosmetic dermatology: Does the aging face need rejuvenation? Should cosmetic dermatology even exist?
A recent Archives of Dermatology article sparked a lively debate about such questions. A wide variety of new popular books have also begun to dissect critical issues. While critiques of cosmetic dermatology range from the conservative ("leave Mother Nature alone") to the feminist ("beauty infatuations subordinate women"), others will ultimately analyze the inherent "goodness" of our field.
What is clear is that physicians who practice cosmetic dermatology assume — or should assume — heightened obligations to their patients. Hopefully, individual practitioners and professional societies can begin to address these concerns now — before the science of and the social demand for cosmetic procedures race so far ahead of the ethical analysis that it will never catch up.
Cosmetic dermatologists must pay careful attention to the duties they owe both their patients and the public. The inherent morbidity of the procedures (even though clearly small), the vulnerability of the patients (some with poor self-esteem) and the special privileges granted to physicians by society all demand a degree of moral conduct on the part of cosmetic dermatologists that clearly surpasses the standard for other suitable business contracts.
Life-enhancing, not life-saving
Additionally, all cosmetic dermatologic procedures are, without any question, embellishments. They are life-enhancing, not life-saving. Physicians engaged in every aspect of aesthetic medicine, including cosmetic dermatology, face inherent conflicts of interest.
Selling cosmetic services or products is a lucrative venture, especially with a market of repeat customers. Physicians' livelihoods depend on performing the very interventions they recommend. But economic self-interest is so much less obvious when a surgeon insists that a sick patient requires cardiac surgery, even if the surgeon stands to profit from the procedure, than when a cosmetic dermatologist or surgeon sells a patient an expensive cream of dubious value.