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Viewpoint
Using "anti-ageing" to market cosmetic surgery: just
good business, or another wrinkle on the face of medical practice?
Anne L Ring
MJA2002; 176 (12): 597-599
Potential consequences of the deregulation of advertising by
doctors are examined using the example of practitioners who promote
cosmetic procedures by exploiting body image concerns in a society
that is both ageing and youth-oriented.
Within the past five years, medical practitioners have seen major
changes to the ways in which they are entitled to promote their
services in Australia. The current approach was formalised as
a result of the State-by-State deregulation of advertising by
doctors through concerted action by the Australian Competition
and Consumer Commission (ACCC), which did so in order to enable
equal opportunity to all businesses in compliance with the National
Competition Policy.1,2 Box 1 outlines the current conditions for
medical advertising.
In 1998, the then Head of the NSW Health Care Complaints Commission
(HCCC) sounded a cautionary note about the risks to the medical
profession from a shift to "competitive principles",
and the potential effects of this in compromising the traditional
medical ethics that have guided the behaviour of members of the
profession "since Hippocrates".1
Concerns about implications for the profession have also been
expressed by the Australian Medical Association (AMA), with one
of the key points in its current position statement on advertising
and endorsement being that:
"The promotion of a doctor's medical services as if the
provision of such services were no more than a commercial product
or activity is likely to undermine public confidence in the medical
profession."4
Evidence that some practitioners of cosmetic surgery were in
the vanguard of the profession in promoting their services in
this way was presented to the New South Wales Inquiry into Cosmetic
Surgery conducted in 1999 by the NSW HCCC. The Committee of that
Inquiry concluded that a number of the promotional practices "may
be in breach of professional standards and fair trading laws".5
Two years on, the ways in which a subset of plastic and other
cosmetic surgeons continue to promote their practice2,6 require
the medical profession to consider, fair trading laws aside, some
important questions about the implications of such commercial
strategies for both the cosmetic surgery sector, and for the profession
as a whole.
It should be noted that the term "cosmetic surgery",
as used in this article, is in accordance with its definition
by the NSW Committee of Inquiry into Cosmetic Surgery. Key points
of that definition are listed in Box 2.
Are ethical standards a casualty in the promotion of cosmetic
surgery?
Doctors strive to prolong life, and have earned some of the credit
for the fact that we are living in a society that is ageing healthily
as our life expectancy continues to grow. It is therefore somewhat
anomalous that the public face of cosmetic surgery includes promotions
which play on the insecurities associated with the superficial
consequences of ageing. Specifically, there is considerable evidence
that the highly profitable tactic of targeting the appearance
of ageing as an undesirable quality is being exploited by some
medical practitioners, using methods similar to the beauty industry's
approach of stigmatising this normal bodily process.
The allegation that doctors have made a substantial contribution
to the reconstruction of ageing for profit is, of course, not
new.7,8 By 1990, in America, Naomi Wolf (in her book The beauty
myth7) had described a key marketing strategy for cosmetic surgery
— namely, classifying ageing as ugly, and ugliness as a disease
for which cosmetic surgery practitioners had the most effective
treatment.7 She also questioned whether such exploitation of women's
insecurities about their appearance was "subject to the ethics
of the genuine medical profession".7
These are now matters that also need to be examined in the Australian
context. This can be done on the basis of examples of anti-ageing
strategies drawn from Australian media and attributed to Australian
medical practitioners. The following examples fall into two categories:
textual References, and the use of enhanced and idealised
images that could be construed as misleading. The majority of
the examples come from recent issues of Australian Cosmetic Surgery
Magazine.9 This is a quarterly publication distributed through
newsagents since 1998 (by which time, it should be noted, advertising
by doctors had been deregulated in the three most populous States
in response to the requirements of the ACCC10). Key aspects of
this magazine are that:
Many of the articles are identified as being authored by, or
substantively based on interviews with, named medical practitioner
contributors.
Many of the contributors also have an advertisement within the
magazine, either on the same page as one of those articles, or
in another part of the magazine.
The contributors are introduced in an illustrated list at the
front of the magazine.9
It is relevant to note that, while there are substantial and
often publicly aired areas of professional conflict between different
categories of surgeons who practise cosmetic surgery,5,11 they
use similar promotional strategies within the covers of Australian
Cosmetic Surgery Magazine.9
Text messages
Typically, negative comments about the appearance of ageing have
focused on aspects of the face and skin (usually, but not always,
in reference to women).
Box 3 shows examples of the ways in which some doctors have characterised
normal bodily changes as undesirable changes in appearance. In
each of the articles from which the quotes were drawn, the doctor
offered cosmetic solutions to the targeted features.
Enhanced and idealised images
Since the linking of questionable anti-ageing images and cosmetic
surgery was raised in Australia in 1998,12 quite a lot has happened,
and nothing much has changed. Examples of "ideal" and
enhanced images used in magazines were presented to the 1999 NSW
Inquiry into Cosmetic Surgery.5 The key elements of the images
that were presented included a number of tactics that are standard
practice in the beauty industry. They have, however, been specifically
criticised as being neither appropriate nor acceptable promotional
strategies for medical practitioners. The NSW Inquiry, for example,
concluded that advertising practices that "may be in breach
of professional standards and fair trading laws" included:
"use of models, implying the model has had the procedure
or that the procedure can achieve the results (with or without
a disclaimer)"; and
" 'before-and-after' photographs that have been enhanced,
or are different in size, colour or pose, or give a misleading
impression of long-term effects of a treatment".5
One of the outcomes of the Inquiry was the recommendation for
development of a guide by the ACCC and the HCCC "on the application
of fair trading laws to the promotion of health services".5
When the guide was published, both of the above practices were
specifically targeted as potentially misleading.3
It is therefore highly significant that, over a year after the
publication of the guide, many of the same, or very similar, kinds
of photographs were still being used. Examples of such illustrations
can be seen in magazine advertisements and in a more neutral and
widely accessible form of commercial media, the Yellow Pages telephone
directories. Some advertisements for cosmetic surgery, for example,
include photographs of youthful and idealised female features,
or enhanced "after" pictures. These images provide a
graphic demonstration of the gulf between the promotion of cosmetic
surgery and the promotion of other areas of medical practice at
this time.
Where does cosmetic surgery belong?
"Anti-ageing" is one of the most powerful contemporary
marketing devices used by the beauty industry. Essentially, it
involves exploiting the insecurities wrought by the appearance
of ageing, and is a part of the broader strategy of promoting
idealised or enhanced standards of appearance as an incentive
for buying cosmetic products and services.7 It has a long-established
history of targeting women, and, more recently, men, and functions
under the socially accepted banner of caveat emptor.
The issue here, however, is not whether such tactics are a good
or a bad thing or to make any such moral judgements. It is the
question of their place within the practice of medicine, as conventionally
defined; that is, as "the science or practice of the diagnosis
and treatment of illness and injury and the preservation of health".13
Concerns about the place of cosmetic surgery have, in fact, been
raised by some of its practitioners. For example, the NSW Inquiry
into Cosmetic Surgery cited the Australian Society of Plastic
Surgeons (ASPS) as expressing "concern about the promotion
of an attitude that cosmetic surgery is just another beauty product".5
A member of the ASPS placed the blame for this attitude on "women's
magazines, regrettably, and the media generally".5 However,
as the examples cited in this article suggest, "the media"
may only be part of the problem, and it is noteworthy that, at
the same Inquiry, a cosmetic surgeon described his area of practice
in the following terms:
"You have to recognise that cosmetic surgery is the nearest
thing you're going to get to retail medicine — or retail surgery.
You're not treating sick people, we're not treating people who
need to have pathology addressed. This is the surgical or medical
end of the beauty industry".14
Certainly, there is evidence that the ASPS is right in its reported
perception of how the media is currently constructing cosmetic
surgery. Recent editions of the magazines Good Medicine and the
Australian Women's Weekly (AWW), for example, both classified
anti-ageing features involving cosmetic surgery solutions in the
"beauty" and "fashion and beauty" sections
of their respective contents pages.15,16 Each of the ensuing feature
stories expanded on the legitimacy of that location. The introductory
text to the Good Medicine article, "Lift your spirits",
stated that:
"Sophisticated medical technology is making cosmetic surgery
an increasingly popular beauty option for many thousands of Australians
who want to give themselves a much-needed boost of confidence."17
AWW's story, "Stop the clock", presented a range of
"cosmetic fixes", stating in its introduction:
"Even the most effective anti-ageing creams can only do
so much — that's why an increasing number of women are turning
to cosmetic surgeons and dermatologists for high-tech treatments."18
Statements such as these suggest that "anti-ageing"
cosmetic surgery and allied procedures are being socially classified
as a beauty want rather than a health need. This classification
also applies more broadly to the practice of cosmetic surgery
as a whole, and is, in fact, consistent with the definition of
cosmetic surgery given earlier in this article as the basis for
the NSW Inquiry into Cosmetic Surgery.5
At this early phase of deregulated advertising by doctors, the
nature of cosmetic surgery, and the perhaps consequent way in
which some of its practitioners have adopted commercial strategies
from the beauty industry, has clearly opened up some interesting
areas of debate for the medical profession as a whole.
Should current promotions of cosmetic surgery be a focus of professional
concern?
First of all, there is the issue of cosmetic surgery itself,
and the extent to which some ways of promoting this burgeoning
area of medical practice meld with accepted visions of what being
a doctor is all about. Do such visions include the application
of medical technology, techniques and procedures to consumer needs
which have been defined as "non-medical",5 and with
what may be seen as some of the sophistry of commercial advertising
techniques? More specifically, does the profession see the latter
aspects of such applications as simply an extension of core business
for doctors, or a worrying expansion into a grey area of mixed
allegiances and hazy ethical boundaries that need to be examined?
What are the implications of commercially structured promotional
strategies for the tradition of "Trust me, I'm a doctor"?
It could, more broadly, be argued that the way in which cosmetic
surgery is being promoted by some practitioners in Australia today
makes it an important test case for how the medical profession
and the community want to see the future direction of the profession
develop. The AMA's concerns, cited at the beginning of this article,
about the potential for such promotional strategies to "undermine
public confidence in the medical profession"4 need to be
taken seriously.
Would the continuing and potentially expanding use of such strategies
presage a decline in the role of trust within a doctor–patient/client/consumer
relationship? And would any such decline be of concern to the
medical profession, or just be seen as a natural and acceptable
consequence of a progression towards the more commercialised practice
of medicine?
1: Advertising: what doctors can and can not — and should and
should not — do*
The National Competition Policy requires that "strict controls
on advertising" have to be eased "where anticompetitive
effects do not have countervailing public benefits". However,
the subsequent changes in the laws do not result in a "free
for all where anything goes". Advertising and other promotional
activity must comply with:
the rules of the Commonwealth Trade Practices Act 1974, which
prohibits a range of misleading, deceptive and unconscionable
conduct, and misrepresentations;
the relevant State and Territory Fair Trading Acts; and
"any specific medical and health practitioner regulations
that remain".
Some equivocation applies, however, with regard to the distinction
that the Trade Practices Act draws between misleading content
and "puffery or self-evident exaggeration". While there
is a reluctance at the legal level to elevate puffery "to
the status of potentially misleading conduct", it is recommended
that – in the case of complex areas such as medical and health
care – puffery "should be avoided or used with extreme caution".
This echoes a broader caveat laid down for practitioners: that
consumers "are best protected when they are fully informed
and when medical and health professionals maintain professional
and ethical standards".
* Drawn from a 2000 guide to the Trade Practices Act 1974 (Cwlth)
for health and medical professionals.3
2: Current parameters of cosmetic surgery
Cosmetic surgery:
is any cosmetic procedure "performed to reshape normal structures
of the body or to adorn parts of the body, with the aim of improving
the consumer's appearance and self-esteem";
"is initiated by the consumer, not medical need"; and
"excludes reconstructive surgery which is . . . [generally]
performed to improve functions, but may also be done to approximate
a normal appearance".5
3: Quotes from cosmetic and plastic surgeons*
". . . lower face and neck . . . is the area where the by-product
of ageing is most obvious with defects such as 'turkey neck',
double chin, jowl fat and platysma bands. This area is most susceptible
to gravity pull and is usually regarded as the ageing area . .
."
". . . as a natural part of the ageing process, most people
develop deposits of fat underneath the eye and on the eyelid which
make them appear older than they are . . ." [included for
its curious logic].
". . . as we age, the globe of the eye tends to descend
and fall backwards due to gravity and subcutaneous fat fades away.
This causes the eyelids and folds around the eyes to become crepey
[sic] and wrinkled giving an untidy and withered appearance .
. ."
* From publicly available magazines published in 2000 and 2001.
References
Walton M. Competition policy and the regulation
of the medical profession. Aust Health Consumer 1998; 1: 10-13.
Ring A. Cosmetic surgery and the body as work-in-progress. In:
Gaskill D, Sanders F, editors. The encultured body: policy implications
for healthy body image and disordered eating behaviours. Brisbane:
Queensland University of Technology, 2000: 61-74.
Australian Competition and Consumer Commission/Health Care Complaints
Commission. Fair treatment: guide to the Trade Practices Act for
the promotion of medical and health services. Canberra: Australian
Competition and Consumer Commission, 2000.
Australian Medical Association. Position statements: advertising
and endorsement. Available online through <http://www.ama.com.au/web.nsf/doc/WEEN-66K2YZ>
(accessed 30 August 2005).
Committee of Inquiry into Cosmetic Surgery. The cosmetic surgery
report: report to the NSW Minister for Health – October 1999.
Strawberry Hills (Sydney): Health Care Complaints Commission,
1999.
Ring A. Body imagery in advertising: just unreal — or also unhealthy
enough for regulatory action? In: Browne C, Edwards K, Watson
V, van Krieken R, editors. TASA 2001 Conference. The Australian
Sociological Association Conference Proceedings CD. Sydney: University
of Sydney, 2001.
Wolf N. The beauty myth. London: Vintage, 1990.
Haiken E. Venus envy: a history of cosmetic surgery. Baltimore:
John Hopkins University Press, 1997.
Australian Cosmetic Surgery Magazine. Sydney: Bella Media, 1998-.
Ring A. The marketing of cosmetic surgery: doctors and the beauty
trade. Aust Health Consumer 1999; 2: 20-22.
Anon. Be informed. Australian Cosmetic Surgery Magazine 2002;
Issue 15, Feb-Apr: 22.
Ring A. The countdown to new heights of sexist ageism in the media
of the new world order. In: Alexander M, Harding S, Harrison P,
et al, editors. Refashioning sociology: responses to a new world
order — TASA conference proceedings. Brisbane: Queensland University
of Technology, 1998: 87-96.
Brown L, editor. The new shorter Oxford English dictionary – Vol.
1 (A-M). Oxford: Clarendon Press, 1993.
NSW HCCC. Cosmetic surgery inquiry transcript [for] 12 April 1999.
Strawberry Hills (Sydney): Health Care Complaints Commission,
1999.
Good Medicine 2001; October: 4.
Australian Women's Weekly 2001; October: 7.
Lovelace K. Lift your spirits. Good Medicine 2001; October: 76-79.
Anon. Cosmetic fixes. Australian Women's Weekly 2001; October:
132.
(Received 19 Nov 2001, accepted 10 May 2002)
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