In this post, Jean McHale reflects on the General Medical Council’s latest guidance on cosmetic procedures.
New Guidance on cosmetic procedures has been produced by the General Medical Council “Guidance for Doctors who offer cosmetic interventions” (GMC 2016). The document demonstrates growing awareness of the changing dynamics of clinician-patient relationship and the requirement to behave ethically in this area. Cosmetic procedures are being placed on the regulatory map and doctors who do not comply may be disciplined by their professional regulatory body. So far, so good. But look a little deeper and it is clear that, in many respects, the Guidance is not the radical revolution it might first appear. Various aspects of the guidance, such as those concerning safety and quality, reflect existing GMC Guidance concerning doctors including the documents: “Good Medical Practice” (GMC 2013); “Good Practice in prescribing and managing medicines and devices” (GMC 2013); “Leadership and management for all doctors “(GMC 2012); and Raising and acting on concerns about patient safety (GMC 2012).
In this new guidance, the GMC stresses the need for informed consent. In practice, of course, informed consent – in the sense of a patient centered approach – has long been part of the GMC professional Guidance. This has been the case from as long ago as 1998 and is reflected in “Consent: Patients and Doctors making decisions together“. Moreover, as the Supreme Court in Montgomery v Lanarkshire Health Board ( UKSC 11) confirmed in 2015, informed consent is now part of English law. The need to ensure patients should not feel rushed or pressurised as it is reiterated in the new Guidance reflects existing legal obligations – to be lawful consent must be voluntary and not subject to force. A notion of patients having a cooling off period provided for in the Guidance is to be welcomed and surely should be routine as part of any informed consent practice save where, due to an emergency, it is necessary to proceed quickly. The Guidance also makes clear the need for effective business ethics in the cosmetic surgery business. This includes explaining charges clearly and being clear as to what a quoted price includes.
The new Guidance does mention provision of cosmetic procedures to children and young people and reference is made to existing GMC Guidance “0-18 years: guidance for all doctors” (GMC 2007). But while it says that interventions should only be provided “in the best interests of the child or young person,” there is no real attempt to engage with the myriad complex legal and ethical issues which arise in that context other than general guidelines in relation to best interests (See J.V.McHale “Children, cosmetic surgery and perfectionism: a case for legal regulation” In P. Ferguson and G. Laurie (eds) Inspiring a Medico-Legal Revolution: Essays in Honour of Sheelagh McLean Ashgate (2015)). Although one particularly interesting recommendation in the new guidance is that marketing activities “must not target children and young people through either their content or placement” (GMC 2016: para 35).
The Guidance suggests the need for continuity of care, what should happen in relation to any complications and who should be contacted in the event of such issues. But it does not put the onus on the surgeon who has performed the procedure to rectify that procedure in the event that it goes wrong. This raises the question of the NHS being left to correct mistakes in emergency situations at considerable cost to itself. The clinician is expected to “support patient safety” in making “full and accurate records”. However, this simply states what is obvious in relation to all clinical procedures – it is not a specific cosmetic surgery question. Contributing to safety measures such as a breast implant register goes further than is currently the case, but while this aspect of the Guidance deals with surgical and non-surgical procedures (such as Botox), it is addressing a group of practitioners who are already regulated through their role. The recommendations highlight the role of the clinician as gatekeeper. If the doctor believes that “the intervention is unlikely to deliver the desired outcome or be of overall benefit to the patient [she] must discuss this with the patient and explain [her] reasoning. If, after discussion [she] still [believes] that the intervention will not benefit the patient [she] must not provide it. [The doctor] should discuss the options available to the patient and respect their right to seek a second opinion.” (GMC 2016, para 18).
The clinician must act ethically and effectively be prepared to turn business away if it is not clinically appropriate. Professional ethics must trump commercial considerations. This raises a very interesting question of the extent to which this does indeed happen in private practice and how many self-paying patients are turned away from practitioners as a result. In relation to business the GMC also emphasizes such things as the need for responsible marketing (GMC 2016, para 49) and “not using promotional tactics” such that this could encourage someone to make an unwise decision (GMC 2016, para 52). Moreover the need for honesty in financial dealings is emphasized (GMC 2016, paras 55-56).
Overall, the new Guidance represents a step in the right direction, but, as my colleague Melanie Latham has said in an earlier blog, much more needs to be done in relation to the regulation of cosmetic procedures. Paradoxically here we are talking about further regulation of one of the most regulated aspects of cosmetic procedure practices the profession itself. Much much more needs to be done to ensure that patients have safe, responsible and ethical practice and I echo Latham’ s call for clearer and more comprehensive regulation in this area.
Jean McHale is Professor of Healthcare Law at the University of Birmingham and Director of the Centre for Health Law, Science and Policy. She is interested in the legal regulation of cosmetic procedures at both domestic and EU level and has a special interest in relation to children and cosmetic surgery.