Written evidence submitted by Nuffield Council on Bioethics [MISS0065]




Dear Ms Nokes,


Thank you for inviting me, on behalf of the Nuffield Council on Bioethics, to give evidence to the Committee’s inquiry on body image on 23 September.


At the end of this evidence session, Elliot Colburn MP asked the Nuffield Council on Bioethics to write to the Committee to set out the 27 recommendations we made in our 2017 report Cosmetic procedures: ethical issues.


Attached to this letter is a list of these recommendations, along with a brief update on what has happened with respect to each recommendation since our report was published.


We also endorsed all Keogh’s recommendations, and argued that they should be implemented in full. The failure to act on many of these - in particular statutory regulation of practitioners providing invasive non-surgical treatments, and the creation of prescription-only status for dermal fillers - continues to put those using these treatments at unacceptable risk.


We would be delighted to provide the Committee with further information on our work in this area, should that be useful to your inquiry.


Yours sincerely,



Professor Clare Chambers

Member, Nuffield Council on Bioethics
































David Archard



Carol Brayne

Simon Burall

Victoria Butler-Cole

Melanie Challenger

Clare Chambers

Tara Clancy

John Coggon

John Dupré

Frances Flinter

Elaine Gadd

Andy Greenfield

Anne Kerr

Shaun Pattinson

Michael J Reiss

Mehrunisha Suleman

Susan Tansey

Christine Watson



Hugh Whittall


Assistant Directors

Catherine Joynson

Peter Mills

Katharine Wright




Recommendations and updates


Recommendation 1


We recommend that the Advertising Standards Authority and the Committee of

Advertising Practice follow the example of Transport for London in prohibiting

advertising that is likely to create body confidence issues, or cause pressure to

conform to an unrealistic or unhealthy body shape.




Recommendation 2


We recommend that the Advertising Standards Authority and the Committee of Advertising Practice revise their guidance to industry to make clear that the following practices are not acceptable in advertisements:


  • claiming, or strongly implying, that there is a likely link between cosmetic procedures and emotional benefit;
  • using post-production techniques in circumstances where they can potentially contribute to discriminatory attitudes, unrealistic appearance ideals, or appearance-related anxiety.




Recommendation 3


We further recommend that the Advertising Standards Authority works proactively to monitor compliance with such standards, in line with its recent commitments to devote more resources to proactive review of advertisements and its ongoing work on body image.




Recommendation 4


We recommend that the social media industry (including Facebook / Instagram, Snapchat, Twitter and YouTube) collaborate to establish and fund an independent programme of work, in order to understand better how social media contributes to appearance anxiety, and how this can be minimised; and to take action accordingly.




Recommendation 5


We recommend that Ofcom review the available evidence and consider whether specific guidance to accompany its Broadcasting Code is warranted with respect to the tacit messages about body image and appearance ideals that may be conveyed by makeover shows involving invasive cosmetic procedures.




Recommendation 6


We recommend that the Equality and Human Rights Commission:

  • develop and publish specific guidance on disfigurement and appearance-related discrimination, founded on the requirements of existing equality legislation; and
  • take discrimination related to appearance into account when monitoring discrimination relating to areas such as age, race, gender and disability.




Recommendation 7


We recommend that the Department for Education act to ensure that all children and young people have access to evidence-based resources on body image, whether through PSHE (personal, social, health and economic education) lessons or through other (compulsory) elements of the curriculum.




Recommendation 8


We recommend to the European Commission that the ‘common specifications’ for the clinical assessment of cosmetic devices, to be developed under the Medical Devices Regulation 2017, should be based on the need proactively to demonstrate both safety and effectiveness with respect to their claimed benefits through clinical trial data and robust outcome measures. CE marking should also be dependent on commitments to collect and publish long-term outcome data.




Recommendation 9


We recommend that the Department of Health and the Medicines and Healthcare products Regulatory Agency, in the lead up to Brexit, develop a UK approach to the regulation of cosmetic devices based on the need proactively to demonstrate both safety and effectiveness with respect to their claimed benefits through clinical trial data and robust outcome measures. Marketing authorisation should be dependent on commitments to collect and publish long-term outcome data.




Recommendation 10


We recommend that the Department of Health bring forward stand-alone legislation to make all dermal fillers prescription-only.




Recommendation 11


We recommend that, until new standards relating to safety and effectiveness of cosmetic devices are in place, insurers of cosmetic practitioners (including the medical and dental defence organisations who provide indemnity cover as a benefit of membership) should, as a matter of good practice, restrict indemnity to procedures using dermal fillers approved under the US regulatory system by the FDA.




Recommendation 12


We recommend that the Royal College of Obstetricians and Gynaecologists should review its guidance to its members on female genital cosmetic surgery and emphasise the need for evidence, demonstrating safety and effectiveness with respect to claimed outcomes, before procedures are offered outside a research setting.




Recommendation 13


We recommend that the Home Office should clarify the circumstances in which procedures offered as ‘female genital cosmetic surgery’ do, or do not, fall within the ambit of the FGM Act, in the light of ongoing concerns as to their legality.




Recommendation 14


We recommend that the Royal College of Surgeons require, and enable, all members of the College who practise cosmetic surgery to participate in its certification scheme.




Recommendation 15


We recommend that the Royal College of Surgeons work with the other surgical Royal Colleges, the major private providers of cosmetic surgery, and professional

bodies representing surgeons working in the cosmetic sector, to ensure that those wishing to specialise in cosmetic surgery are able to access the training that they need to achieve the necessary standards.




Recommendation 16

We recommend that the General Medical Council and the medical defence associations work together to ensure that surgeons who are performing cosmetic surgery must meet these requirements in order to be indemnified when performing such surgery. One possible approach would be through the proposed ‘credentialing’ scheme currently being developed by the General Medical Council.




Recommendation 17


We recommend that other regulatory bodies whose registrants provide cosmetic procedures, in particular the General Dental Council and the Nursing and Midwifery Council, develop specific guidance on cosmetic practice for their own registrants, to complement the guidance issued by the General Medical Council and the Royal College of Surgeons.




Recommendation 18


We recommend that, once the Joint Council for Cosmetic Practitioners has achieved accreditation with the Professional Standards Authority, Public Health England and its counterparts in the other countries of the UK should initiate a public awareness campaign to publicise the existence of the quality mark, alongside other sources of user advice, once available. Such a campaign should also draw attention to the lack of regulatory controls on practitioners not covered by the quality mark.




Recommendation 19


We recommend that the Department of Health act to extend the role of the Care Quality Commission (CQC) to all premises where invasive non-surgical procedures are provided.



Recommendation 20


We recommend that the CQC review its registration and inspection criteria for providers of cosmetic procedures so that, as a minimum providers are held responsible for:

  • ensuring that surgeons providing services under contract to them are certified under the Royal College of Surgeons’ scheme, once fully in force;
  • ensuring that any practitioners providing non-surgical procedures under their name are registered with a body accredited by the Professional Standards Authority (when non-surgical procedures are brought within the CQC’s remit); and
  • taking the lead in responding to any complaints and litigation in connection with care provided under their name, regardless of the employment status of the practitioner concerned.




Recommendation 21


We recommend that the UK departments of health should work with the Royal College of Surgeons, the Joint Council for Cosmetic Practitioners, the Private Healthcare Information Network, and the Care Quality Commission to find ways to close the significant gaps in data collection that currently remain.




Recommendation 22


We further recommend that the clinical codes used by the NHS to record and classify patient information should be adjusted to enable the NHS to record accurate information about any complications of cosmetic practice that require follow-up treatment in the NHS.




Recommendation 23


We recommend that the UK departments of health work with the relevant health regulators, Royal Colleges, professional associations, and major provider organisations to ensure that children and young people under the age of 18 are not able to access cosmetic procedures, other than in the context of multidisciplinary healthcare.




Recommendation 24


We recommend that the major providers of cosmetic procedures collaborate with both the relevant professional bodies, and users of cosmetic procedures, to fund the independent development, regular updating, and wide dissemination of detailed information for users about both surgical and non-surgical procedures.




Recommendation 25


We recommend that the major providers of cosmetic procedures jointly develop a code of best practice to which they, and all practitioners working in their name, should adhere. Such a code should include:

  • Recognition of the importance of clear distinctions between sales staff and practitioners, with ‘consultations’ and ‘advice’ only offered by appropriately qualified staff.
  • Commitment to shared decision-making and a two-part consent process, with no financial commitments asked of users before the end of this process.
  • Recognition of the limits of one’s experience as a practitioner, and commitment to multidisciplinary practice.
  • Commitment to obtaining information where necessary from the user’s GP, as a default position.




Recommendation 26


We recommend that the UK Research Councils and other major research funders should actively encourage high quality interdisciplinary research proposals that aim to fill the significant gaps in the evidence base identified in this report with respect to the provision and use of cosmetic procedures. Such research is essential in order to promote more ethical practice in the sector. In addition to the recommendations already made with respect to much improved data collection, we highlight the need for research:

  • to improve understanding of the factors associated with poor outcomes after cosmetic procedures, and the development of practical tools to help practitioners identify and support prospective users who are more likely to have such outcomes; and
  • to improve the evidence base with respect to the long-term physical and psychological outcomes, both positive and negative, of different cosmetic procedures.




Recommendation 27


We recommend that the Care Quality Commission should require all providers within its remit to guarantee access to an independent arbitration service, in cases where complaints cannot be resolved to patients’ / users’ satisfaction at provider level.




September 2020