Practicing ethical dermatology

March 1, 2006

Especially in the cosmetic arena, it is easy for dermatologists to become enthusiastic about trying something new. But ethical experts suggest they take a step back and think before pushing.

When it comes to ethical practice, all the rules seem to boil down to one. As the American Academy of Dermatology (AAD) Ethics Committee Chairman Robert D. Greenberg, M.D., puts it: "No matter what the procedure or treatment, an ethical doctor's recommendation to the patient should be what, in the doctor's estimation, is in the patient's best interest."

The American Medical Association (AMA) agrees, according to Priscilla Ray, M.D., a psychiatrist who practices in Houston and chairwoman of the council on ethical and judicial affairs at the AMA.

"The main statement is that our work and ethical considerations are basically that we have to put the patients' needs first. That is the global statement. The others derive from there," Dr. Ray says.

Dr. Greenberg, who practices in Vernon, Conn., says that just as there are guidelines in how to treat patients medically, there are also guidelines in how to treat patients ethically. The AAD's administrative regulations titled "Principles of Professional Conduct" offer general principles, reminding Academy members of their ethical obligations and providing standards and guidelines for members to follow.

"The principles are standards of honorable behavior by which each member of the Academy may evaluate his or her relationships with patients and colleagues," Dr. Greenberg says.

"One of the major principles in the guidelines is that the physician should provide only those services that are in the patients' best interests, and that are medically necessary and/or appropriate for the patient's condition. The number and types of procedures performed should not exceed those actually needed, or in the case of cosmetic or other discretionary procedures, requested by the patient."

This scenario illustrates a dermatologist's ethical obligation: An attractive, middle-aged woman comes to the dermatologist for a laser resurfacing procedure, and the dermatologist determines that her skin is in very good shape.

The ethical physician might recommend that the woman not undergo the procedure because it would not be in her best interests, Dr. Greenberg tells Dermatology Times.

The temptation to perform procedures for self-interest might occur if a dermatologist has just purchased an expensive laser, and he or she has to perform a certain number of cases in order to make the purchase financially viable.

"When you have a new hammer, everything looks like a nail," Dr. Greenberg says. "From the standpoint of having a new piece of equipment or learning a new procedure, the dermatologist ethically has to remind himself or herself that it is to be used appropriately for what the patient's condition warrants and for what is in the patient's best interest."

Conflicts of interest

Selling, endorsing and recommending products are ethically sticky areas for dermatologists who financially benefit from the sales or have financial interests in the companies that make the products.

The ethical party line in these cases, according to Dr. Greenberg, is that physicians should always be mindful of conflicts of interest. Dermatologists should disclose any conflicts of interest involving selling, endorsing or recommending products or performing procedures.

"A dermatologist should exercise all reasonable alternatives to ensure that the most appropriate care is provided to the patient. If the conflict of interest cannot be resolved, the doctor should notify the patient and refer that patient to a non-conflicted colleague for care," Dr. Greenberg says.

"Once the patient is made aware that the physician stands to benefit and there is a competing interest in that recommendation, the patient can then make an informed decision about the doctor's recommendation."

Dr. Ray says that dispensing products in the office might put pressure on patients to feel as though they should comply with their doctors' suggestions. Dermatologists and other doctors selling health-related products should keep in mind, among other things, that those products must have scientific validity.