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  • Ethical action, like informed consent, is a process.

  • Most ethical challenges occur when there are conflicting principles, conflicting duties, or conflicting concepts of to whom the greatest—or least— ethical allegiance is owed.

image Beginner Pearls

  • For centuries, philosophers have struggled with the distinctions between ethics, morality, law, and—more recently—professionalism.

  • Ethics reflects a social imperative that is based on moral underpinnings; ethics can therefore be conceptualized as morality in action.

image Expert Pearls

  • Professional morality may be broader and deeper than common morality, as it addresses the moral expectations for a particular group.

  • Principlism, perhaps the most popular ethical framework, relies on the (equally weighted) principles of autonomy, beneficence, nonmaleficence, and justice. These four principles are frequently used as a litmus test for ethical legitimacy.

  • Morality is a social institution, and the common morality represents the core group of morals that are considered universally binding.

image Don’t Forget!

  • Other approaches to ethical decision-making abound, including utilitarianism, aspirational ethics, casuistry, deontological approaches, rights theory, and virtue ethics.

  • While cosmetic dermatology patients may interact with physicians as if they are consumers, rather than patients, they should still be treated as the latter.

image Pitfalls and Cautions

  • Keep in mind that there is often more than one reasonable solution to an ethical quandary.

  • An action can be legal without being ethical and ethical without being legal.

  • Body dysmorphic disorder is a common condition, and identifying such patients is an important challenge for the cosmetic dermatologist, not least because the patient is likely to be dissatisfied after any intervention.

  • The need for a consistent ethical framework led to the expansion of principlism to the point that the four principles are frequently used as a litmus test for ethical legitimacy, though the challenges of this model of applied ethics may be substantial.


Appreciating and understanding the fundamentals of bioethics is of significant importance for dermatologic surgeons, both in order to better assess and evaluate the nature of ethical challenges and to better engage in informed ethical decision making. The epistemology of bioethics—how we know what falls within the boundaries of ethical actions and what does not—is worth exploring not simply as an intellectual exercise, but as a stepping stone to expanding our understanding of why a particular act is or is not the appropriate choice in any given situation.

Despite a 200-year trend of codifying ethical and professional mores, the subjective nature of morality and ethics may be challenging, particularly for physicians whom, as scientists, expect an objective and standardized system rather than a relativistic amalgam of duties and principles.

Ethical challenges may be of several varieties. Sometimes, a true moral or ethical dilemma is present, while at others the central challenge is a practical dilemma, where a sense of ethical obligation ...

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