Ethical Issues in the Beauty Salon:The Development of National Ethics Guidelines for Aestheticians in the Netherlands
The Netherlands awoke with a shock to some highly publicized cases of clients suffering second-degree burns from inadequate use of laser technology for hair removal in the beauty salon. Aestheticians are increasingly offering risky and sometimes irreversible skin-enhancing treatments. Because of the complexity and hazards of the beauty profession and its proximity at times to the domain of health care, it merits attention from bioethicists. This article presents an overview of ethical issues arising within the everyday practice of the beauty salon, based on discussions with aestheticians and a survey, and reports on the development of the world's first national ethics guidelines for aestheticians. Key recommendations pertain to age limits, informed consent, confidentiality, tensions arising from aestheticians' dual role as care providers and entrepreneurs, and the management of incidental findings. This article directs scholarly effort at ethical issues in the beauty salon, and invites further discussion of a hitherto underserved field.
Aestheticians, Beauty Salon, Ethics Guidelines, Mixed-Methods Study, Professional Ethics, Bioethicists, Informed Consent, Confidentiality, Incidental Findings
Although the beauty sector is vast and growing, it has so far received little scholarly attention from bioethicists or medical ethicists (ISAPS, 2015). This is understandable, as health care and cosmetology have traditionally been worlds apart: mostly, aestheticians cleanse, care for, and enhance the already healthy and intact facial skin (see definition below). In some ways, the aesthetician's profession is not far removed from that of the medical doctor. Beauty treatments are not free from risks; although in many countries aestheticians are not allowed to perform minimally invasive cosmetic interventions, such as Botox or filler injections (Panteia, 2014; Gerson, D'Angelo, Deiz, & Lotz, 2013), they do carry out interventions such as chemical peeling, laser therapy, or micro-needling, thereby removing [End Page 247] or puncturing the surface layers of the skin. As consumer demand for advanced skin enhancement and rejuvenation is rising, aestheticians are foraying more deeply into the skin, using more complex chemical substances or technical equipment, and offering ever more risky and irreversible treatments.
What are aestheticians?
Though terminologies and practices may differ across countries, aestheticians are roughly understood to have received 3–4 years of formal vocational training, to be skilled at conducting basic and advanced facial skin treatments using specialized products and equipment, and to be knowledgeable about skin anatomy and physiology as well as skin care and disorders. Aestheticians can be independent salon owners, employers at large salons or spas, employees, or freelancers. Their work is to be distinguished from that of hairdressers and persons who perform only manicures and pedicures, who focus on cosmetic treatments for hair, hands, and feet, respectively, and will have received different types of training. Although "aesthetician" is not a protected title in many countries, including the Netherlands, aestheticians can be considered professionals, understood broadly as those who perform jobs that require skills and formal training.
In the Netherlands, the news media have increasingly reported on women suffering adverse results from failed cosmetic procedures. In 2014, a case of second-degree burns resulting from incorrect use of laser technology for hair removal in the beauty salon was highlighted in an episode of a nationally televised consumer information program (Radar, 2014). In response to such incidents, the Dutch Minister of Health, Welfare and Sports announced measures to increase oversight of the cosmetic sector in the Netherlands (Schippers, 2015). In other countries, including the UK, parties calling for tighter regulatory control of the beauty sector press for the clarification of responsibilities of professionals in health care and related fields (UK Department of Health, 2013; Nuffield Council on Bioethics, 2016). ANBOS, a Dutch professional body that represents around 70% of the country's approximately 10,000 aestheticians (Panteia, 2014), observed that some of the problems confronting the beauty sector may result from a lack of awareness, knowledge, and skills among aestheticians related to professional ethics. ANBOS felt that the beauty sector in the Netherlands stood in need of ethics guidance.
ANBOS asked the Department of Medical Ethics and Philosophy of Medicine at Erasmus MC, University Medical Center Rotterdam, to develop guidelines to help aestheticians deal with ethical issues encountered in everyday practice. In response, we devised a research project consisting of two parts: first, an inventory of ethical issues in the beauty salon; and second, the development of normative guidance for aestheticians. The research team conducted regular group interviews with an advisory board over the course of a year, in addition to informal interviews with aestheticians at professional events. We also developed and conducted a survey in order not only to map the ethical dilemmas confronting aestheticians in their everyday work environments, but also to elucidate their best practices and the norms and values they bring to bear on these dilemmas. Based on the best practices we identified and on existing professional ethics guidance from adjacent fields, notably that of medical ethics, we developed recommendations for dealing with the many ethical issues encountered in the beauty salon.
Aestheticians can be considered care providers, not just service providers. They tend to describe their work as oriented toward well-being rather than appearance, and toward making clients feel better (Sharma & Black, 2001). Furthermore, they are increasingly collaborating with medical specialists, supporting and complementing medical care. For instance, Dutch aestheticians have participated in "Teledermatology" projects, sending images of suspect lesions through a secure online connection for same-day dermatological evaluation [End Page 248] (U-Consultancy, 2016). Also, groups of oncologists and aestheticians have set up training programs for administering beauty treatments to cancer patients, which are meant to contribute to pain management and rehabilitation (Nelis & Vandenreyt, 2015). Moreover, the legal gap between the beauty and health care sectors may be closing; the Healthcare Quality, Complaints and Disputes Act explicitly applies to aestheticians as care providers, too (Wkkgz, 2016). As aestheticians are becoming recognized as care providers, they are also expected to act as professionals. The establishment of a code of ethics is often an important part of professionalization processes (MacKenzie, 2007).
The beauty salon, like other care environments, is fraught with ethical issues. Although aestheticians may not be trained to recognize, verbalize, or systematically address ethical dilemmas, these situations do arise in the everyday execution of their work. This article maps the key ethical issues of the beauty salon. Also, it describes the process of developing national ethics guidelines for aestheticians in the Netherlands by a group of bioethicists. To our knowledge, these guidelines are the first to be developed anywhere in the world.
An advisory group was established consisting of eight members (six female, two male, ages ranging from 49 to 77) purposively selected through ANBOS. All had ample experience in the field, including aestheticians who had managed larger institutions, taught specializations, served on professional boards, and/or written for professional magazines. The group met monthly at ANBOS headquarters in Woerden over the course of a year, for 3- to 4-hour discussions moderated by the research team (EB and FM). Nine meetings were convened in total. Most participants were present at all meetings.
The first sessions were group interviews aimed at identifying ethical issues and discussing cases, guided by questions such as "What makes a good aesthetician a good aesthetician?" or "How do you reconcile being an entrepreneur and a care provider at the same time?" or "When looking at the menu of treatments on offer in your salon, what message are you conveying about beauty ideals?" The discussions were not audio-recorded. EB kept notes on a laptop, selectively quoting members of the advisory board verbatim. Translations into English were done by EB. Based on a thematic analysis of early group discussions, the research team identified 17 issues to be explored in greater depth and addressed in the guidelines. Later sessions were aimed at reaching consensus regarding best practices and recommendations with regard to the 17 issues, in discussions moderated by EB and FM. Over time, the advisory group became aware of the existence of a rich, elaborate professional ethics that characterizes and underpins their daily work.
Further, the research team drew on informal interviews with (younger, female) aestheticians conducted by EB at beauty salons in The Hague and Amsterdam (n = 3). Also, EB attended two beauty trade fairs and professional training events in more rural regions to observe and informally interview attending aestheticians (n = ~12) during breaks about topics ranging from the treating of children to incidental findings, from training to equipment, and from informed consent to domestic violence. EB made notes and used paper-based and simple word processing methods to identify themes, which were reviewed by the advisory group. Also, Web searches were conducted to identify norms, values, codes of conduct, and best practices on national and international Websites. Finally, in the trade magazine Schoonheidsspecialist [Aesthetician], EB and FM wrote monthly columns about the project, discussing ethical issues and eliciting responses and cases from readers.
A 27-question survey was developed by the research team, in collaboration with a member of the advisory board, about key recommendations from the draft guidelines. The survey was then distributed among an existing panel consisting of approximately 7,000 economically active individuals registered as "skin care, pedicures, manicures" [End Page 249] professionals with the Netherlands Chamber of Commerce. Panel members are regularly invited by Van Es Marketing Services, a market research agency commissioned by a publisher of beauty trade magazines (Uitgeverij Lakerveld B.V.), to take part in surveys related to the beauty sector, usually pertaining to its business aspects. In the email invitation for our survey, which was developed by Van Es using SurveyMonkey, the topic (ethics) was deliberately not mentioned so as to prevent bias from two sources: a lack of responses from invitees who ignored the survey because of unfamiliarity with the topic, or a disproportionate number of responses from those who were especially passionate about it. After 2 weeks, nonresponders were sent a reminder email. In total, 431 invitees (6.2%) opened the survey, which is a normal response rate for this panel. Respondents who were not aestheticians (e.g., those who offered manicures or pedicures exclusively) were excluded from the analyses. A total of 255 aestheticians completed the survey. The research team received the raw data, including all answers to open questions, as well as a report from the research agency in a standard format, using unweighted statistics. The report (in Dutch) is provided as a supplement to this article here: http://hdl.handle.net/1765/106043. The results were used to check the comprehensiveness and relevance of the draft guidelines in respect to aestheticians' current practices.
Development of the guidelines
Based on the empirical work, the research team identified the norms and standards that guided everyday practice and/or best practices in the beauty salon, continually checking them with our advisory board. Also, the research team built on and adapted established standards within bioethics, such as the four classic principles of medical ethics, beneficence, non-maleficence, and respect for autonomy and justice (Beauchamp & Childress, 1986), as well as principles derived from the Hippocratic oath (KNMG, 2004). For instance, the research team would ask the advisory board, "Do you feel that a duty of confidentiality applies to you?" and, if the answer was "yes," follow up with "To what extent and/or under what conditions does this apply?" We were also guided by existing national and international codes of conduct for aestheticians (e.g., Register of Beauty Professionals, 2016), skin therapists, and physiotherapists, and aestheticians' Websites. Often, it was through the group discussions with our advisory board, drawing on their wide and long practical experience, that we as ethicists could distill moral norms and recommendations for the beauty salon.
The guidelines were aligned with existing standards such as the Dutch Aesthetician's Code (ANBOS, 2009b), a "practical guide for a better business" that offers standards for technical aspects and processes in the beauty salon, including disinfection, hand hygiene, occupational hazards, and the maintenance of installations. Apart from safety considerations and informed consent forms, however, the Code does not address any ethical issues. Also, the guidelines were developed to be in keeping with the everyday practice and experience of aestheticians, and at the same time to "aim high," to inform and elevate the quality of service provided. As the guidelines were to become an integral part of vocational training programs for aestheticians across the Netherlands, they had to be suitable for educational purposes. The researchers sought not to impose any norms from outside of the beauty sector, but rather to bring to light moral norms or standards that have already, tacitly and nondeliberately, been part of aestheticians' everyday practice. With our advisory group, we settled on 17 domains of ethical issues to be addressed in the guidelines and grouped these into ethical themes.
After the draft guidelines were finalized and approved by the advisory group, the research team asked three independent bioethicists/medical ethicists as well as professional organizations (of skin therapists, dermatologists, and general practitioners) for comments and the Board of ANBOS for authorization. In September 2016, the ethics guidelines were published and distributed among aestheticians in the Netherlands (Bunnik, Meulenberg, & de Beaufort, 2016). In the Dutch judicial system, ethics guidelines, like other (e.g., more technical) professional guidelines, help to constitute a professional standard that can be used [End Page 250] as a point of reference in court proceedings, as they point out what can reasonably be expected from practitioners.
Results: Ethical Issues in the Beauty Salon
The 17 chapters of the ethics guidelines for aestheticians represent 17 domains of ethical issues, fitting into 5 overarching themes: professional boundaries, personal boundaries, and integrity and commerce (integrity); information and advice, informed consent, and confidentiality (information); age limits, vulnerable groups, beauty and society, and clients' own responsibilities (responsibility); incidental findings and signs of domestic violence (care); and operational management, file management, handling complaints and errors, interacting with colleagues and other care providers, and training, continued training, and quality assurance (professionalism) (see Table 1). Below, for each theme, we will present a selection of prominent ethical dilemmas encountered by aestheticians in the conduct of their work, in conjunction with some of the main recommendations included in our ethics guidelines. The recommendations are practice-oriented, meant for practical application by aestheticians in the everyday context of the beauty salon.
1. Integrity: "Competent and qualified"
Integrity entails holding oneself to one's moral standards, even when tempted or under pressure to do otherwise. Aestheticians have multiple roles: on the one hand, they are care providers, working to improve the well-being of their clients, and on the other hand, they are entrepreneurs or employees, intent on selling products and continuing the business. Though at times these two roles may be conflicting, they need not be irreconcilable: aestheticians can make money and offer good-quality services or care at the same time. This is part of being a professional, according to our advisory group:
When you present yourself as an "aesthetician"—for instance, through a sign on your door—you present yourself as an expert, as someone who has specific knowledge. That brings along certain responsibilities.
Medical doctors are held to professional standards as formulated in codes of ethics. The Dutch Rules of Conduct for physicians, for instance, state that physicians may not abuse their position of power, may not discriminate against patients, must respect the boundaries of their profession (and thus refrain from interventions that they are unqualified to provide), and must always act in the best interests of their patients (KNMG, 2013). While, unlike doctors, aestheticians are not expected to act in the interests of their clients, our advisory group argued that they are expected not to act against their clients' interests. They may recommend (overly) expensive at-home skin care products, but not when they believe that the product will fail to address clients' skin care needs. Aestheticians should not take advantage of their clients, and, under all circumstances, should also ensure adequate care provision.
For our advisory group members, an aesthetician's professional integrity starts with knowing her or his boundaries. The work domain of the aesthetician is restricted to the skin: "We are allowed to work only on the intact skin." Dutch aestheticians are taught that they can work on the skin or in the skin, but not through the skin (ANBOS, 2009b; 2013). There are limits, for instance, on the length of micro-needles (0.5 mm) that are used in the beauty salon (De Munnik, 2013). Aestheticians do not give injections (e.g., dermafillers or Botox) or carry out face setting (a minimally invasive needling technique to induce the production of elastin and collagen in the skin), and may treat the intact and healthy epidermis only, not the underlying living layers of the skin (Illinois General Assembly, 1985). When clients are suffering from serious eczema, psoriasis, or other skin conditions associated with open wounds or inflammatory lesions, rendering the skin susceptible to infections, aestheticians should refuse or postpone treatment. As our advisory board pointed out, this sometimes leads to problems:
What if the client insists? What if it's someone who came for skin improvement treatment but has psoriasis with active inflammation? What if she starts saying, "I drove all the way here"?Member B:
You don't do it.Member C:
You offer them an alternative.Member B:
Or you just don't treat them. [End Page 251]
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[End Page 252] When clients have medical complaints, they should be referred to their general practitioners, dermatologists, or other doctors.
Although basic beauty treatments typically involve cleansing or cosmetics, aestheticians are increasingly offering skin improvement treatments aimed at ameliorating signs of acne, hyper-pigmentation, rosacea, psoriasis, or scarring, or skin rejuvenation treatments aimed at countering the visible effects of aging. In our survey, 68% of aestheticians indicated that they offer such "specialized" treatments. This number is higher (87% and 90%) for respondents who have one or more specialized diplomas. Specialized treatments affect the skin more deeply, may involve the use of aggressive ingredients (e.g., chemical peelings) or technological devices (e.g., Intense Pulsed Light (IPL)/laser, mesotherapy, microdermabrasion) that require additional knowledge and skills, or may lead to irreversible outcomes (e.g., permanent hair removal or make-up). When aestheticians offer such specialized—and thus more risky and irreversible—treatments, they should be competent and qualified to do so by receiving and maintaining [End Page 253] specialized training. In our survey, however, 35% of respondents offered specialized treatments without having completed any additional specialized training. This finding is in line with an earlier report on the nature and extent of the cosmetic sector in the Netherlands (Panteia, 2013). Our advisory board was very concerned about this finding: "This is wrong because people can be harmed." In response to concerns raised over the past few years, ANBOS is setting up a publicly accessible quality registry that consumers can check to see whether their aesthetician has completed a certified basic 3-year vocational training program and/or holds diplomas for specializations. It was felt by our advisory group that it is of the utmost importance that aestheticians refrain from offering specialized treatments for which they have not been adequately trained, and that concerted action must be undertaken to prevent harms resulting from such practices in the future.
The theme of professional integrity encompasses the protection of aestheticians' own boundaries. A British aesthetician says that aestheticians "are the type of people who like to help others (… They) just love pampering people and making them feel better" (Doyle, 2006). In our advisory board, we discussed the extent to which aestheticians have a role to play in enhancing their clients' psychological well-being:
I am not a psychologist; it is not my duty to help a client deal with mental problems.Member B:
Of course not, of course you are not going to treat her in any clinical way.Member C:
But by treating her, by adapting your treatment specifically to her skin, at the end of the day, she is going to feel better because of you.
Touch and physical contact are part of a beauty treatment, as is (partial) undressing and exposure of the naked skin. Physical contact in the beauty salon, however, should always be functional, not intimate.
2. Information: Informed consent and confidentiality
Aestheticians will generally know more about skin care than their clients do. With aestheticians' knowledge advantage come professional responsibilities, including a duty to inform. According to our advisory group, adequately trained aestheticians should explain what they see on their clients' skins, and what they do for these conditions and why, in clear and understandable language. They should inform and advise clients about skin care that is attuned to clients' skin types, and may recommend at-home skin care products. They should ensure that their claims are truthful and evidence-based and do not raise overly optimistic expectations. As a member of our advisory board said,
A degree of temptation, of exclusivity, of "feel good," is part of the pampering that goes on at the beauty salon. Clients are okay with cosmetic products containing a little bit of "cosmos," a little bit of magic, and are willing to pay for it…. But aestheticians should temper clients' expectations that caviar, gold, crystal, DNA, or stem cells contained in a day cream will make them look ten years younger.
For specialized treatments or other treatments that are risky or irreversible, aestheticians must seek clients' informed consent. The client should be made aware of the benefits, risks, implications, and limitations of the proposed treatment (ANBOS, 2009b). Dutch aestheticians who offer IPL/laser treatments are advised to use a model form for informed consent (ANBOS, 2011), which lists potential adverse effects of the treatment such as hypo- or hyperpigmentation, redness, blisters, or bruises; points out its limitations, explaining that multiple treatment sessions may be required and that it may be difficult to predict the outcome of the treatment; and mentions contra-indications, such as exposure to sunlight or self-tanning products. This way, the informed consent process not only expresses respect for clients' autonomy, but also enables them to protect themselves from harm. Ideally, an informed client would stop and say, "I should not be taking this treatment now, I am going away on a sunlit holiday next week." One of our advisory board members said,
Informed consent is the front door to the treatment…. There is a phase for reflection, as well. [… Clients need] space to learn about what will happen.
Also, informed consent implies that clients should be able to make voluntary decisions about [End Page 254] undergoing beauty treatments. Our advisory group indicated that female clients are sometimes pressured by others into undergoing hair removal, (permanent) make-up, or other treatments. Our survey corroborated this, as one respondent wrote,
A man asked me to put heavy make-up on his wife…. He sent me a photograph, and it was so horribly vulgar that I couldn't do it. His wife was very modest, and in consultation with her I applied a pretty make-up instead…. The husband phoned me a couple of times that week, [… angry] that I hadn't done what he wanted.
The guidelines state that aestheticians should only proceed with beauty treatments when they are convinced that clients choose autonomously, without pressure or coercion (Faden & Beauchamp, 1986). Pressure may also be subtler, as many people want to meet beauty ideals (Etcoff, 2000; Kuczynski, 2008). When clients seem to follow (unaesthetic) fads or request radical changes, aestheticians should inquire into their motives and goals. Sometimes treatments should be postponed so that aestheticians can take the time to talk with clients and let them think about their wishes.
Although a legal duty of confidentiality does not apply to aestheticians as it does to medical doctors, many do adhere to a self-imposed moral duty of confidentiality. One Dutch aesthetician states on her Website, "Everything that is discussed in my salon will remain within its four walls. My profession has a duty of confidentiality, too." Our advisory board concurred:
This most definitely applies to us. Confidentiality also fits with touch. That is how trust and openness arise. As an aesthetician, you have to protect that.
Clients will talk about marital or financial problems, about their children or siblings or neighbors. In our survey, we assessed how aestheticians deal with personal information when a client has not indicated that such information is confidential; 85% of respondents will not share personal information about clients with anyone at all, while 10% will talk about this information, but without naming its source.
One of the beauty sector's main trends at the moment is the relationship between food and appearance (In-Cosmetics, 2015; Franchise Help, 2016). When aestheticians provide information or recommendations related to food, health, and skin condition, they should take care not to harm their clients. For instance, in one case described by a member of the advisory board, an aesthetician recommended cranberry juice in response to a client's bladder complaints. Rather than seeing a doctor, the client drank large amounts of cranberry juice and developed pyelonephritis. In another case, an aesthetician recommended soy to her client, not knowing that the phytochemical it contains could have adverse effects on the hormone treatment for breast cancer that the client was undergoing.
Finally, aestheticians are responsible for the quality and safety of all devices or equipment used in the salon. Since we were curious to know to what extent aestheticians feel capable of shouldering this responsibility, we included questions in our survey about equipment. Forty-one percent of respondents indicated that for their appraisal of equipment, they rely on information provided by the supplier, and 34% agreed with the statement "I cannot tell whether information provided by the supplier is correct." Our advisory board was especially concerned about less experienced aestheticians:
All these young aestheticians attending trade fairs, they have to really stand their ground. All those companies that are promising them golden mountains with these devices … when you know that it's not going to work.
Our advisory group thought the lack of technical knowledge to be an area of immediate concern for the beauty industry. Efforts to improve quality and safety in the cosmetic sector must address these knowledge gaps, promoting informed decision-making with regard to the purchasing of new equipment and improving aestheticians' skills and know-how in handling this equipment.
3. Responsibility: Dealing with vulnerable clients
Aestheticians, as professionals and as care providers, take on responsibilities. When clients sit or lie down in the salon, they entrust themselves to their aestheticians, who they expect to have the [End Page 255] knowledge and know-how that they themselves lack. They trust aestheticians to take care of their skin and improve its condition. They may purchase products and treatments recommended to them, and, afterwards, at home, they may follow their aestheticians' skin care instructions. In response to this trust, aestheticians are held responsible for the adequate, safe, and effective execution of beauty treatments. They should be truthful and caring. Also, they should pay extra attention to clients who may be vulnerable, including children, those who are sickly or elderly, or clients who lack the capacity to make autonomous decisions. Although taking responsibility may at times run counter to aestheticians' own (financial) interests—as one of our advisory board members said, "Sometimes I have to do a lot of talking just to talk people out of getting certain treatments"—there are times when clients must be protected against themselves or others.
Sometimes, minors or young children may seek beauty treatments, either on their own initiative or with the encouragement of parents or guardians. Our respondents treated an average of 9.1 children over the preceding 2 years, mostly performing cleansing or acne treatments, hair removal (through epilation, waxing, and IPL/laser), the removal of milia cysts or warts, make-up treatments, manicures, and pedicures. In order to treat clients who are under 18 years old, aestheticians should ask, at a minimum, one parent or guardian for consent. Specialized treatments such as IP/laser or permanent make-up should in principle not be offered to minors at all (ANBOS, 2011). Exceptions may be made when the benefits of a treatment outweigh the risks: for instance, when a child suffering from the social and psychological consequences of excessive hair growth is treated with IPL/laser by an experienced aesthetician, and the child's general practitioner or primary care physician is involved.
Aestheticians should refrain from, for instance, epilating the eyebrows of a 13-year-old girl into narrow lines, for the hairs may never regrow. They are advised to postpone beauty treatments that are risky or irreversible until adulthood, when clients can make autonomous choices. In our survey, we included the following question: "What should aestheticians do when a mother brings her 10-year-old child to the salon and asks for epilation of the child's unibrow?" Eighty-one percent of our respondents would treat the unibrow only when both mother and child give consent; 15% would refuse to treat the unibrow, because the child is too young to make informed choices; 10% would initiate a private consultation with the child to evaluate the child's motivations, apart from those of the mother; and 4% would treat the unibrow when the mother wants it, for it is the mother who is responsible for the child (respondents could choose more than one answer). Sometimes aestheticians may need to resist the (well-meant) wishes of a parent in order to protect a child. Aestheticians are free to have and uphold personal moral boundaries, and to refuse participation in a beauty treatment. However, they should be able to give a valid explanation. An aesthetician who does offer treatments to minors states on her Website,
Do note that it is not our intention to turn young children into fashion dolls. We wish to teach teenagers in the age range of 14–16 about caring for one's skin and hair in a responsible manner.
Members of our advisory group were concerned about clients who are dissatisfied with their looks or "people who are bullied" about their looks. Aestheticians see themselves as tasked with making clients feel better and look better, through touch and relaxation, and by showing clients what it is that makes them beautiful. But when clients have unrealistic expectations about the effects of a beauty treatment, they may end up dissatisfied. Over the past two years, respondents to our survey were confronted with on average of 2.8 clients who had unrealistic expectations. When asked how they dealt with such clients, 58% of our respondents agreed with the statement, "If I do not believe that the treatment will meet the client's goals, I will not do it"; 40% would talk to the client until their goals were adjusted so as to become attainable; 15% agreed with the statement "If I suspect a psychological problem, I refer the client to a health professional"; and 15% would talk to the client, but if he or she persisted, they would abide by the client's decision and carry out the treatment. Aestheticians should always [End Page 256] explain carefully what they can and cannot do to ameliorate their clients' appearance, and should not heed clients' wishes when these are unrealistic. This is in line with rules of conduct for physicians and/or physician-researchers, who should, for instance, not give in to patients' requests for unnecessary treatments (Campbell, Pham-Kanter, Vogeli, & Iezonni, 2013), and actively rebut the "therapeutic misconception" in research participants, who may (falsely) expect a medical benefit from their participation (Appelbaum, Roth, & Lidz, 1982).
When clients are preoccupied with a (perceived) defect in their appearance in a way that seriously distresses them or impairs their daily functioning, they may be suffering from body dysmorphic disorder (Phillips et al., 2010), and may need the help of a psychiatrist. In such cases, aestheticians should advise clients to consult their primary care physicians.
4. Care: Incidental findings
To a certain extent, aestheticians are expected to care for their clients. The relationship between aestheticians and their clients is asymmetrical, the former knowing more about the skin than the latter. When aestheticians detect abnormalities on the skin that merit clinical attention—so-called incidental findings—they are advised to inform their clients about these findings, especially when by doing so they can help prevent serious harm. This is in line with recommendations for clinicians, (bio)medical researchers, and commercial service providers: when incidental findings are clinically significant and actionable, they should be reported (Presidential Commission, 2013; Bunnik, van Bodegam, Pinxten, de Beaufort, & Vernooij, 2017). Likewise, when they notice signs of domestic violence, they may raise this issue within the safe and confidential atmosphere of the treatment room, and offer their help. When aestheticians provide this level of care to their clients, they are not exceeding the boundaries of their profession. Rather, they are employing their knowledge advantage and/or the confidentiality of the aesthetician-client relationship to promote their clients' well-being.
The primary task of aestheticians lies in caring for or improving the healthy skin, not in detecting medical problems. Still, aestheticians get to see the skin of their regular clients often, much more frequently than general practitioners or dermatologists, and do at times detect abnormalities on or underneath the skin. According to our survey, aestheticians detect mostly (early stages of) skin cancer or other skin conditions, but also diabetes, neuromuscular disorders, endocrine disorders, tumors, cysts, and aneurysms in the neck. When the aesthetician deems an abnormality potentially clinically relevant, she should inform the client, write down her findings in the client's file, and recommend that the client consult with their general practitioner. Seventy-three percent of our respondents would do so, and would follow up on the finding during the next visit. Some respondents write reports of their findings for the client to bring along to their doctor. One respondent wrote,
I find it difficult to talk to clients when I suspect skin cancer…. But I did help clients because it turned out to be skin cancer…. So it is hard but it is really important.
A member of our advisory group suggested that checking for early-stage skin cancer can even constitute a routine part of the beauty treatment: "Some of my clients ask every time: 'Will you check my back for moles?'" On average, our respondents detected 12.7 incidental findings in the course of 2 years.
Aestheticians should be watchful for signs of domestic violence or sexual abuse: not only because of a general moral responsibility to rescue, as would apply to all citizens, but also because aestheticians stand in a professional relationship with clients who entrust part of their body and well-being to them for the duration of the beauty treatment. Based on this partial entrusting of (parts of) the body to the professional, it can be argued, the professional has care obligations over and above those applying to ordinary citizens (Richardson, 2008). When Dutch aestheticians detect signs of domestic violence, they should follow the Dutch reporting code (Ministry of Health, Welfare and Sports, 2014). [End Page 257]
5. Professionalism in the beauty salon
As aestheticians in the Netherlands are positioning themselves as professionals, they are responsible for maintaining and improving the quality standards of their services. Aestheticians are bound by their professional code (ANBOS, 2009b), which specifies minimum requirements with regard to hygiene, safety and labor conditions (e.g., physical strain, working with potentially dangerous compounds, management of needle-stick injuries), personal protective measures, design of the treatment room, personnel, sustainability, permits, and insurance. For instance, aestheticians must be vaccinated against Hepatitis B (ANBOS, 2009a). In our survey, 54% of respondents indicated that they were vaccinated, but 25% stated, "No, I don't need to be"—which is not correct. In addition, the ethics guidelines warn against fraud and disproportionate remuneration, and present a stepwise approach to the handling of client complaints. Members of our advisory group indicated that they had regularly observed signs that young female aestheticians, especially, are confronted with transgressing behaviors by (often male) clients. Senior aestheticians are expected to protect their employees and interns against such behaviors, and teach them how to deal with these behaviors effectively. Also, employees and interns who have not completed specialized training may not be asked to offer specialized treatments, not even as a "helping hand" or under the supervision of a qualified aesthetician. As members of the advisory board pointed out,
As an employer, you cannot place your employees in a situation where they are violating the regulations. There should be serious fines for this.Member B:
It happens. Employers who are supposed to be training the interns, but are letting them run the business by themselves. Employers who aren't even there.Member C:
Now, that is moral mismanagement.
The advisory board felt that employers should assume responsibility for interns: "through providing education to young aestheticians-in-training we can ensure that future consumers will be in trusted hands in the beauty salon." Addressing maltreatment of junior employees by senior staff and/or by clients was considered by the advisory group to be a priority for future work by educators and by ANBOS.
The guidelines include recommendations with regard to file management. In anticipation of the new European General Data Protection Regulation (European Commission, 2016), they state that personal data may only be stored, processed, or used when there is a distinct, explicitly circumscribed and justified purpose for doing so, and when the client has provided consent. Consequently, aestheticians may store data related to skin treatment in clients' records, but not data pertaining to clients' personal lives (e.g., "daughter graduating this year" or "divorced in the spring"). Aestheticians must take measures to protect the privacy of clients' data, and must notify clients when data leaks occur.
Like other care providers, aestheticians are advised to pursue life-long learning (KNMG, 2013). Basic knowledge of adjacent fields will help aestheticians interact effectively with medical doctors, skin therapists, or other care providers. Specialized training is a sine qua non for the offering of specialized treatments, and triennial continued training is required to maintain one's registration as a specialist. In addition, aestheticians are advised to attend professional or trade meetings and to arrange for continued learning to keep their knowledge and skills up to date, and for inter- or supervision to help them learn from others. Our advisory board felt that aestheticians should be "open toward feedback or criticism from colleagues." Calling each other to account is part of professional self-regulation.
Professional bioethics is no longer a prerogative of medical doctors and physician-researchers. Other care providers are claiming this field, too, and not without reason. Aestheticians are better trained and more organized than they were in the past, pushing for the improvement of safety and quality standards, both technical and ethical, in their field. Also, they are using more complex, high-tech [End Page 258] equipment and more deeply penetrating chemical compounds. Ethical issues encountered in the beauty salon range from the treatment of those who are unable to provide informed consent to truthful communication about skin care products, from privacy and data protection to the management of incidental findings and signs of domestic violence, and from the protection of junior employees to the requirements of life-long learning. In our national guidelines we present recommendations and best practices for 17 domains of ethical issues, fitting into 5 themes: integrity, information, responsibility, care, and professionalism. Also, we identified 3 areas of immediate concern. First, aestheticians are not always adequately trained and qualified to perform specialized procedures that are increasingly risky and irreversible, which may pose threats to consumers' safety. Second, some aestheticians may lack the technical knowledge to understand and take responsibility for the equipment that they use in the beauty salon. Third, there are indications that junior beauty professionals may be insufficiently protected against both unwarranted demands from employers and transgressive behaviors from clients. Although tightening state oversight of beauty salons could help to address these concerns, professionalization of aestheticians from within could be equally important in further improving the quality and safety in the cosmetic sector. National ethics guidelines are a major step in this process of professionalization, and may help to raise moral standards in the beauty salon. With this article, we hope to raise awareness among our colleagues of the existence of ethical issues in the beauty salon that merit closer attention from bioethicists in the future.
This article is a result of a project funded by ANBOS, a trade association for aestheticians, and conducted at the Department of Medical Ethics and Philosophy of Medicine at Erasmus MC. The authors would like to thank the members of the advisory group, Judith van Eersel-Savert, Mary Faber, Ad van Gaalen, Simone Keijzer, Marleen Kila, Tine Ploeg, Monica Pruis-Meerburg, and Herman van Venetië and Kees Hoogendijk of ANBOS, for their commitment and their priceless contributions to the development of the ethics guidelines.
Conflicts of Interest. The authors have no conflict of interest to declare.