Introduction
A variety of factors must be considered when an individual seeks aesthetic interventions. According to a study published in JAMA Dermatology, the main reasons patients sought aesthetic interventions included improving their cognitive well-being, aesthetic appearance, and psychosocial functioning (Gorbis, 2019). It should be pointed out, however, that a person may seek aesthetic treatment due to the effects of a debilitating psychological illness referred to as body dysmorphic disorder (BDD) (Gorbis, 2019).
Roughly 13.1% of people who request cosmetic interventions are diagnosed with BDD (Gorbis, 2019). Practitioners need to be equipped with the skills to identify BDD in patients and refer them to mental health specialists for management. The condition’s prevalence and the potential harm aesthetic treatments may cause to affected individuals necessitate appropriate treatment. The decision-making processes associated with the assessment of BDD patients, from history-taking to diagnosis and management, ought to be safe, appropriate, and aligned with ethical principles in healthcare.
Clinical Consultations
The Royal Pharmaceutical Society (RPS) Competency Framework focuses on two key aspects of the patient-practitioner relationship. The first is the consultation domain, which examines the competencies that the prescriber ought to exhibit during the consultation (Royal Pharmaceutical Society (RPS), 2021). The second area of focus is prescription governance, which pertains to the competencies a prescriber must exhibit in administering drugs (RPS, 2021).
All practitioners are expected to conduct consultations in appropriate settings. In addition, they must consider the patient’s dignity and capacity for consent, assess their communication needs, demonstrate professionalism, and document all relevant aspects of the clinical assessment (RPS, 2021). Each of the aforementioned domains ought to be applied in the context of the ethical principles of autonomy, beneficence, non-maleficence, and justice, as they apply to individuals diagnosed with, or suspected of having, BDD during clinical consultations.
Diagnosing Body Dysmorphic Disorder
Body dysmorphic disorder (BDD) is a psychiatric condition typified by an excessive fixation on perceived or minor flaws in one’s appearance that are often invisible to others. In accordance with the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), BDD falls within the category of obsessive-compulsive disorders that are different from eating disorders (Pereira et al., 2023). In the overall population, the estimated prevalence ranges from 0.7% to 2.9% (Pereira et al., 2023). Depending on the demographics and criteria used, the prevalence of BDD varies, although it is generally believed to be higher among patients seeking facial cosmetic procedures (Pereira et al., 2023). Affected individuals demonstrate a set of specific symptoms as defined in the DSM-5.
The correct classification of individuals with BDD is critical for making an accurate diagnosis. According to the DSM-5, BDD is also characterized by the existence of repetitive behaviors or mental acts at some point in the course of the illness, in response to the individual’s worries about their appearance (Hostiuc et al., 2022). In addition, affected individuals experience serious distress or limitations in various areas of functioning as a result of their preoccupation with the apparent defect (Hostiuc et al., 2022). Finally, in an individual whose symptoms fit the diagnostic criteria for an eating disorder, the preoccupation with appearance is not better explained by worries about weight or body fat (Hostiuc et al., 2022). Each of the above-mentioned criteria is essential to formulating an accurate diagnosis and implementing appropriate treatment.
Treatment Planning and Monitoring
The adoption of effective treatment strategies is essential to effectively addressing BDD. People with the condition may be reluctant to engage in mental health treatment since their insight is typically lacking or non-existent, meaning they are mostly convinced that their appearance is ugly or deformed (Castle et al., 2021). Many of the affected individuals would rather get cosmetic surgery, even though such a strategy is ill-advised (Castle et al., 2021).
Therefore, to engage and retain affected individuals in therapy, motivational techniques and more thorough psychoeducation may be necessary (Castle et al., 2021). The choice of intervention is based on consideration of the Royal Pharmaceutical Society’s guidelines. Regarding prescription governance, practitioners are expected to prescribe up-to-date medications or devices to address specific medical conditions and to demonstrate an understanding of the potential adverse effects and benefits of their prescriptions (RPS, 2021). Each of the highlighted conditions must be met to effectively address the needs of individuals diagnosed with BDD.
The predominant pharmacological treatments for BDD consist of clomipramine and selective serotonin reuptake inhibitors (SSRIs). Patients should be informed that the above-mentioned dosages exceed the maximum limits recommended by regulatory bodies in most countries. Patient monitoring is a vital step in the management of BDD. An SSRI trial of 12–14 weeks is recommended for BDD treatment, with at least 3–4 of those weeks at the highest dosage permitted by regulatory bodies (Castle et al., 2021). This will help determine whether the medicine is sufficiently beneficial to continue. If slower titration is employed, a longer trial period is required.
Ethical Considerations in the Context of the Royal Pharmaceutical Society Competency Framework
Autonomy
Regardless of their initial wishes, a patient who desires a cosmetic operation and requests it without a valid medical reason is expected to demonstrate complete autonomy. It is considered unethical to perform such a procedure on a patient who lacks complete autonomy (Hostiuc et al., 2022). This is because there are no medical indications and no way to determine whether the patient genuinely wants the procedure or whether it would benefit them in another way.
Acceptance of the surgery must be based on accurate, comprehensive information about the prognosis, benefits, risks, complications, alternative treatment options, and financial considerations (Hostiuc et al., 2022). Autonomy is typically evaluated either during or after the process of providing a patient with information and obtaining their consent (Hostiuc et al., 2022). To be deemed eligible to sign the consent form, a person must be able to make decisions on their own.
Autonomy in cosmetic patients with BDD should be assessed during the initial consultation. If it is difficult to determine an average level of insight, all cosmetic procedures must be halted. There are, however, other considerations that come into play in assessing autonomy. Autonomy ought to be determined by an individual’s reasoning process and not by the details of their decision.
The patient’s decision should be taken into consideration only when the reasoning process is illogical or demonstrates a lack of comprehension (Hostiuc et al., 2022). In addition, autonomous decisions should not always be viewed as good choices. In some cases, poor decisions might be justified if they are supported by logical reasoning (Hostiuc et al., 2022). Finally, a person who can choose for themselves should be capable of critical thought, of making decisions based on reason, and of defending those conclusions through the articulation of their personal values.
Beneficence
Beneficence is an ethical principle that emphasizes health practitioners’ moral duty to do good. Beneficence can be understood as satisfaction with certain medical procedures, particularly those in plastic surgery (Hostiuc et al., 2022). The utilitarian theory of morality, which holds that happiness or well-being is the greatest desideratum at both a personal and population level, forms the basis of the aforementioned ethical principle (Hostiuc et al., 2022).
According to this perspective, a medical procedure is morally acceptable if it produces satisfaction, even in the absence of a direct medical benefit. For instance, while an aesthetic rhinoplasty offers no medical benefit, it can have a positive psychological impact by enhancing the patient’s self-image (Hostiuc et al., 2022). This can lead to improved cultural and social conditions, as well as vocational skills and integration, ultimately yielding significant benefits for the patient.
The case for cosmetic operations is frequently justified by conceptualizing beneficence as satisfaction. The key argument is that the procedure’s substantial non-medical benefits outweigh any potential hazards (Hostiuc et al., 2022). However, because BDD patients are frequently dissatisfied with the outcomes of cosmetic procedures, the principle of beneficence as satisfaction does not effectively address their needs. It is worth noting that suicide rates among BDD patients are higher than in the general population, and anxiety and depressive symptoms persist even in the absence of cosmetic surgery (Hostiuc et al., 2022). Cosmetic surgeries for BDD patients may, therefore, not offer any meaningful benefits, thus highlighting the need to have a high index of suspicion.
Justice
Health professionals are required to ensure that everyone has access to medical care. Equitable access to healthcare is a widely recognized fundamental human right supported by the ethical principle of justice. Unfortunately, due to resource constraints, no health service can offer aesthetic surgery to every patient who requests it.
Clinical necessity is often the basis for rationing specific services. This always leads to subjective determinations of which patient’s needs are more important. The identification of BDD is critical, given that it provides an opportunity for the provision of psychiatric care, which supersedes the need for cosmetic surgery.
It should be noted, however, that cosmetic procedures that defy accepted societal norms may have their roots in injustices committed against particular groups of people (Hostiuc et al., 2022). For instance, a non-Caucasian individual seeking an intervention to appear more Caucasian may be motivated more by a fear of being a victim of racism than by genuine dissatisfaction with their appearance (Hostiuc et al., 2022). The aforementioned challenges notwithstanding, the practice of justice for BDD patients involves facilitating access to critical psychiatric care.
Non-Maleficence
Performing a psychiatric evaluation with the appropriate instruments is essential, given the consequences associated with the mismanagement of BDD. According to the principle of non-maleficence, which seeks to do the least amount of harm possible, the above-mentioned medical practice is necessary (Garcia-Sánchez, 2023). Even though most cosmetic clinics do not perform psychological profiling of their patients, it is generally recommended in order to ensure optimal psychological treatment and improvement (Garcia-Sánchez, 2023).
It is important to consider the rise in the number of patients visiting cosmetic clinics with a diagnosis of BDD when formulating interventions to address specific concerns. The medical professional must be informed of the candidate’s past mental health history in order to better understand their clinical condition. In addition, they should seek out any further information from the patient’s primary care physician. Aesthetic surgeries often affect the patient’s mental state, which is why psychological consultation is deemed necessary before any form of intervention.
UK Legal Framework
The law governing the prescription of cosmetic products and interventions governs clinical practice. The United Kingdom has few regulations for safety and quality control for its cosmetic products, including dermal fillers (Huwyler, 2021). Consequently, people can readily purchase potentially hazardous or counterfeit goods from easily accessible stores such as Google or Amazon, except for botulinum toxin, which is classified as a prescription-only medical device (Huwyler, 2021).
On May 26, 2021, the European Medical Device Regulation, which is not applied in the UK, was formally adopted as law (Huwyler, 2021). The Medical Device Directive eliminates the need for further country-level legislation by making specific provisions directly applicable at the national level. Devices for skin resurfacing, collagen implants, dermal fillers, and laser hair removal are all considered medical devices under this law (Huwyler, 2021). This means that a qualified professional needs to prescribe such procedures before they are conducted.
Conclusion
A variety of challenges arise in the administration of treatments to patients diagnosed with body dysmorphic disorder. These include the presence of insight, the necessity of the intervention, and the impact of non-medical benefits. The decision-making procedures that guide the history-taking, diagnosis, treatment planning, and monitoring phases of client evaluation must be appropriate and safe. The recommendations for interventions intended to meet the needs of people with BDD are guided by the framework of accountability and responsibility established by law, ethics, and professional standards. However, while the Royal Pharmaceutical Society offers explicit guidelines for prescriptions, UK law lags behind in regulating cosmetic procedures.
References
Castle, D., Beilharz, F., Phillips, K. A., Brakoulias, V., Drummond, L. M., Hollander, E., Ioannidis, K., Pallanti, S., Chamberlain, S. R., Rossell, S. L., Veale, D., Wilhelm, S., Van Ameringen, M., Dell’Osso, B., Menchon, J. M., & Fineberg, N. A. (2021). Body dysmorphic disorder: A treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders and the Obsessive-Compulsive and Related Disorders Network of the European College of Neuropsychopharmacology. International Clinical Psychopharmacology, 36(2), 61–75.
Garcia-Sánchez, E. (2023). Psychological beneficence is part of the principle of beneficence in non-reconstructive aesthetic surgeries. Medicina e Morale, 72(1), 27–38.
Gorbis, E. (2019). Body dysmorphic disorder and aesthetic procedures. Journal of Aesthetic Nursing, 8(2), 62–64.
Hostiuc, M., Hostiuc, S., Rusu, M. C., & Isailă, O. M. (2022). Physician-patient relationship in current cosmetic surgery demands more than mere respect for patient autonomy—Is it time for the anti-paternalistic model? Medicina, 58(9), 1–12.
Hostiuc, S., Isailă, O. M., Rusu, M. C., & Negoi, I. (2022). Ethical challenges regarding cosmetic surgery in patients with body dysmorphic disorder. Healthcare, 10(7), 1–8.
Huwyler, G. (2021). Unnecessary or negligent? A look into the regulation of non-surgical cosmetic intervention in Europe. Trinity Student Medical Journal, 21(1), 11–13.
Pereira, I. N., Chattopadhyay, R., Fitzpatrick, S., Nguyen, S., & Hassan, H. (2023). Evidence-based review: Screening body dysmorphic disorder in aesthetic clinical settings. Journal of Cosmetic Dermatology, 22(7), 1951–1966.
Royal Pharmaceutica Society (RPS). (2021). A competency framework for all prescribers.
