Enhancement (of What?) in Aesthetic Medicine

Introduction

In September 2012, the High Court of Singapore reversed the judgement of the disciplinary committee (DC) of the Singapore Medical Council (SMC) on the alleged professional misconduct of Dr. Low Chai Ling (the “LCL Case”).¹ Just less than a year ago, she was censured and fined by the DC for failing to comply with regulatory guidelines on publicising and administering five minimally-invasive procedures in aesthetic medicine.² These procedures, being mesotherapy for fat deposits, mesoglow, stem cell extract facial therapy, sonophoresis and carboxytherapy, have not been scientifically validated. On appeal, the Court agreed with the DC that aesthetic medicine must have a scientific basis because it is practised by doctors rather than beauticians. The legal responsibilities of doctors are not lowered even if aesthetic medicine differs from conventional medicine in some respect. The Court provides the following description of aesthetic medicine as involving:³

… procedures administered to modify a patient’s appearance through treatment of body structures, and does not have as its primary objective the curing of existing illness or disease. Patients who undergo aesthetic treatments seek to enhance their overall sense of well-being and self-esteem by receiving such treatments. The treatments may be sought to diminish negative attention and/or increase positive attention from others. Often, they involve elective procedures that seek to defer or prevent the onset of the natural effects of the aging process or the gaining of excessive weight.

Unlike beauticians, doctors in aesthetic medicine must ensure that treatments involved are always safe and efficacious in achieving the desired improvement in appearance and well-being. Such assurances must be grounded in evidence-based medicine (i.e., that the treatments have been substantiated and validated by medical research), and not merely because large numbers of doctors engage in the treatments. However, the Court did not ultimately defer to the decision of the DC largely because a number of due process requirements were not met.

This article is not concerned with the procedural requirements in administration of justice. Rather, it attempts to present a contextual meaning of “enhancement”, rather than one that is based on technology per se, or a therapy/enhancement contradistinction. This discussion is pertinent as the LCL Case comes at a time when aesthetic medicine is faced with acute ethical dilemma.⁴ Is aesthetic medicine a business primarily concerned with profit or an integral part of the healthcare system centred on the best interests of patients? If aesthetic medicine is a proper medical subspecialty, how are the various “enhancement” technologies to be understood and what are the considerations in order to deploy them ethically? What about securing professional repute? It is argued that these questions are best answered by examining “enhancement” not in abstraction, but in a more holistic manner that does not necessitate a therapy/enhancement distinction. Unlike the LCL Case, it is further argued that the SMC’s guidelines on aesthetic practice could accommodate such an approach.

Conceptualising Enhancement

When the LCL Case was filed for hearing before the Supreme Court, a medically-trained colleague appeared perplexed when I referred to this development as one concerning aesthetic medicine. The term “medicine” was considered to be an inappropriate description of the practice. In a rather nonchalant reply, I was asked: “Where is the patient?” It is perhaps on this rationale that aesthetic practice appears to have an unsettled place (if a place at all!) in medicine. In its guidelines, the SMC adopts a definition of “aesthetic practice” that was proposed by an expert group in the UK as: “Operations and other procedures that revise or change the appearance, colour, texture, structure, or position of bodily features, which most would consider otherwise to be within the broad range of ‘normal’ for that person”.⁵ This definition is consistent with the Supreme Court’s observation in the LCL Case that aesthetic treatments could be minimally invasive interventions that change bodily features that continue to fall within a “normal” range. They could also encompass invasive procedures (e.g. cosmetic surgery) conducted to “improve” appearance for its own sake. Such procedures include breast augmentation, fat...