Dear Editor:
The global spread of a highly contagious novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has completely transformed the landscape of medicine on multiple levels. From the critical, such as ventilator rationing, to the less urgent, such as office safety measures and patient triage, the coronavirus disease 2019 (COVID-19) pandemic has required physicians to adapt to new ways of providing health care. Many procedural specialties, including cosmetic dermatology, must carefully consider if and how certain procedures are offered, both now and during a potential future infective global illness. Here, we discuss the ethics of performing facial aesthetic procedures in the midst of an international viral pandemic.
As physicians, we are required to adhere to a code of professionalism, pledging to uphold the safety and well-being of our patients in all circumstances.1 The four principles of medical ethics, which are beneficence, non-maleficence, respect for autonomy, and justice, should always be at the forefront of our decision-making process. In light of an ongoing pandemic, dermatologists must pay particular attention to balancing these principles when considering elective facial aesthetic procedures.
According to the principle of beneficence, all procedures performed by physicians should occur with the intent to do good for the patient. The practice of aesthetics aligns well with this principle, as cosmetic procedures can significantly improve patient quality of life, self-esteem, and self-confidence.2 However, this principle also indicates that doctors should prioritize patients’ overall best interests. If one is practicing cosmetic dermatology in a geographic location with high rates of SARS-CoV-2 transmission, defined in New York as a testing positivity rate of higher than 10 percent over a seven-day rolling average,3 is it in a patient’s best health interest to expose them to a medical office for an unmasked aesthetic intervention? Does improving the quality of life for one individual outweigh the optimization of public health through social distancing? Based on the ethical principle of beneficence, the answer to both questions is clearly no.
The principle of non-maleficence dictates that doctors have a duty to not cause harm to the patient or society as a whole. As with the beneficence principle, physicians should always act in the patient’s best interest. Aesthetic procedures have inherent risks that should be discussed during the process of informed consent. However, in the setting of a viral pandemic, one must carefully consider additional risks posed to patients interested in facial rejuvenation. In geographic areas with high rates of viral transmission, facial cosmetic procedures, particularly those of the lower face, might present an unacceptably high risk of harm to the patient undergoing treatment and others alike. This issue becomes more important when a patient with an uncertain COVID-19 status presents requesting a perioral procedure. Even if an office takes all of the necessary precautions in sanitization and social distancing, the risk of having a patient enter a medical facility for an aesthetic procedure requiring removal of a face mask is difficult to justify and not aligned with non-maleficence.
Respect for autonomy refers to the right of competent adults to make informed decisions. Before patients can make fully informed decisions, they must be fully cognizant of the risks and benefits of the treatment at hand. However, the principle of autonomy is not absolute; we must recognize its limits, particularly when a patient consents to a procedure with a risk/benefit ratio so unbalanced that the treating doctor would no longer be acting in the patient’s best interest. When it comes to an aesthetic procedure in the time of a viral pandemic, it is not always sufficient that a patient provides informed consent. It is incumbent upon the treating dermatologist to carefully ascertain if the potential benefit of facial rejuvenation outweighs the risks of viral transmission or acquisition and ensure the principles of beneficence and non-maleficence are met. It is only in this situation that autonomy can support resuming elective procedures.
Based on the principle of justice, physicians must strive for equal distribution of scarce resources. Personal protective equipment (PPE) has been in high demand across the globe since the early months of the pandemic. As we have phased into a new way of providing health care, PPE is now required for patients and staff in all encounters. Utilizing PPE for an elective cosmetic procedure that could instead have been used for intensive care or emergent surgery is not consistent with the ethical principle of justice. As dermatologists, we must recognize that aesthetic rejuvenation procedures must be put on hold if there are not adequate supplies of PPE as reported by local government and hospitals. Keen attention to epidemiological trends in the pandemic will allow us to make informed decisions, in coordination with our colleagues in medicine and public health, regarding the best use of scarce resources.
Many state health departments in the United States have developed an elective procedure algorithm detailing how to balance the urgency of a procedure with the health of a patient. These regulations tend to follow the four tenets of medical ethics. Such suggestions vary by state and county, but cautious and methodical approaches have been recommended by national professional organizations, including the American Academy of Dermatology and the American Society of Plastic Surgeons.4,5 These guidelines recommend previsit screening and minimizing face-to-face contact between patients and staff. Unlike elective nonurgent procedures that do not require patients to remove PPE, such as screening colonoscopies and cataract surgery, facial aesthetic procedures involve even more risk and necessitate more caution on the part of the provider.
Potential ethical conflicts relevant to performing elective facial cosmetic procedures during a pandemic include economic interests, which might lead dermatologists to underestimate viral transmission risk to rationalize performing procedures. As dermatologists, we must always prioritize the well-being of our patients and society. We are not suggesting the closure of purely aesthetic practices; however, as physicians we must recognize that cosmetic practice might not meet the definition of essential business. To continue operating, individual practices must fully account for local COVID-19 transmission rates to adequately determine the safety and risk profile of performing elective procedures.
Dermatologists should always carefully weigh the risks and benefits of performing elective aesthetic procedures; this is now especially pertinent in the setting of an ongoing viral pandemic. In many parts of the United States, SARS-CoV-2 transmission and hospitalization rates are downtrending such that physicians might feel increasingly comfortable performing facial cosmetic procedures with appropriate safety precautions. However, in regions with continued or recurrent high testing positivity rates as defined by state and locality, it is most appropriate to delay facial aesthetic procedures until a time at which local prevalence rates are lower and a favorable risk/benefit ratio has been restored.
While undeniably causing strain on our patients, staff, and practices, the COVID-19 pandemic can provide a unique point of self-reflection for dermatology at large. Many of our colleagues temporarily closed their practices and donated PPE; others have shattered common stereotypes of dermatologists by ceasing to perform aesthetic procedures and volunteering on the front lines. Though the pandemic has affected us in different ways, we have the opportunity to move forward stronger as a specialty. By honoring the four principles of medical ethics and forgoing elective aesthetic procedures in times and locations with high rates of SARS-CoV-2 transmission, we will be able to provide ethical care to our patients, protect the health and well-being of society, and exhibit solidarity with our colleagues in the house of medicine.
With regard,
Lisa Akintilo, MD, MPH and Evan A. Rieder, MD
Drs. Akintilo and Rieder are with the Ronald O. Perelman Department of Dermatology at the New York University Grossman School of Medicine in New York, New York.
Funding. No funding was provided.
Disclosures. The authors have no conflicts of interest relevant to the content of this article.
Correspondence. Evan A. Rieder, MD; Email: evan.rieder@nyulangone.org
References
- World Medical Association. WMA Declaration of Geneva. Available at: https://www.wma.net/policies-post/wma-declaration-of-geneva/. Accessed July 30, 2020.
- Hibler BP, Schwitzer J, Rossi AM. Assessing Improvement of facial appearance and quality of life after minimally-invasive cosmetic dermatology procedures using the FACE-Q Scales. J Drugs Dermatol. 2016;15(1):62–67.
- New York Department of Health. Interim guidance for quarantine restrictions on travelers arriving in New York state following out of state travel. Available at: https://coronavirus.health.ny.gov/system/files/documents/2020/11/interm_guidance_travel_advisory.pdf. Accessed June 24, 2020.
- American Academy of Dermatology. Running your dermatology practice during COVID-19. Available at: https://www.aad.org/member/practice/coronavirus/running-your-dermatology-practice. Accessed July 30, 2020.
- American Society of Plastic Surgeons. COVID-19: resources for plastic surgeons and their practices. Available at: https://www.plasticsurgery.org/for-medical-professionals/covid19-member-resources. Accessed July 30, 2020.