Skin Bleaching as a Dermatologic Intervention Complicity or Service? Case Scenario A 21-year-old African American college student has dis- liked her dark complexion for years. She believes that black women with light complexions have a better life—better grades, better boyfriends, better job opportunities. In her view, these women are treated better by society in ev- ery way. She believes her chances of being successful in life would be appreciably improved if her skin were a few shades lighter. She tries some creams available at a beauty supply store that claim to lighten complexion, and she no- tices a very slight lightening of her skin. She is encour- aged by this change, but wants something stronger. She has heard from a friend that dermatologists can give pre- scriptions for stronger products, so she makes an appoint- ment to see a dermatologist for further assistance in light- ening the color of her skin. There is strong evidence suggesting that lighter skin correlates with a range of social, professional, and even health care advantages over individuals who have darker skin tones. While skin-lightening treatment appears to be reasonably safe and efficacious, 1,2 it raises a weighty ethical dilemma for dermatologists asked to prescribe them to lighten one’s complexion. On the one hand, skin- bleaching treatment can be understood as a valuable ser- vice to the patient, who may very well improve her life prospects owing to the treatment the dermatologist pro- vides. On the other hand, skin-bleaching treatment may be understood as reinforcing the societal racism that ad- vantages lighter skin, possibly making the dermatolo- gist complicit in the continuation of the social ill that gen- erates the patient’s request and the positive impact on the patient’s life chances from the treatment in the first place. Here we lay out the ethical arguments speaking both in favor of and against dermatologic interventions intended to lighten one’s natural complexion with the intention of sparking a dialogue within the field. The First Prong of the Ethical Dilemma: The Argument for Service The patient in our case requests the skin-lightening in- terventions based on her observations that lighter skin confers many benefits in our society. She believes that people will respond more favorably to her, leading to bet- ter job prospects and higher income. And there is em- pirical evidence to support her anecdotal observations. Research shows that lighter complexions are also asso- ciated with better socioeconomic opportunities. Lighter skin color is correlated with preferential outcomes in edu- cation, higher personal and family incomes, and occu- pational prestige, even when controlled for confound- ing factors like English-language proficiency, education, occupation, ethnicity, and race. 3 Lighter skin tone is even associated with better health outcomes: for example, darker skin color has been linked to higher blood pres- sure among African Americans. 4 The preference for and privileging of lighter skin and the discrimination against those with darker skin has been referred to as “colorism.” 5 This preference for lighter skin is a phenomenon that occurs both within and across racial categories, and it is thought to be very much tied to our country’s long history of slavery and racism. The claim is not that colorism is deliberate or premeditated, but that the widespread preference for lighter skin is subconscious and largely internalized. 5 If a dermatologist believes that her patient is a victim of colorism, does she have a duty to use her medical expertise and training to remediate this wrong, aiding the patient in accessing better life prospects? This intervention could offer the patient a means to improve her life chances, from receiving higher wages to accessing better health outcomes. 3,4 There is a com- pelling argument that dermatologists have an obliga- tion to agree to provide the intervention on grounds of the physician’s duty of beneficence. Although this clini- cal duty has traditionally been focused on the preven- tion and treatment of physical maladies, 6 perhaps this duty should be extended to achieve broader patient self-determination and flourishing. Perhaps the physi- cian’s obligation to beneficence should be expanded to include social, interpersonal, or even economic goals. Given that the evidence suggests that lightening the patient's skin is in her best interest, the physician may not only be permitted, but might even be duty-bound, to aid the patient with this request. The Second Prong of the Ethical Dilemma: The Argument for Complicity To find the counter-argument that opposes a physi- cian’s assistance in skin-bleaching, one must merely look to the long history of both racism and skin color con- sciousness in the United States. The preference for light complexions over dark incontrovertibly grows out of, and is buttressed by, racism. Our skin color consciousness was both created during the institution of slavery, and it remains one of its lasting legacies. Skin bleaching is part of that long sordid history. References to skin bleach- ing in the black press go back as early as the 1850s. 5 A French soap advertisement from the 1930s provides an example of the association of blackness with pollution and dirt. The poster shows a dark African man washing his hands with soap, turning them white. 5 Such images of black people lightening their skin with use of cleans- ing products occur frequently in turn-of-the-century product advertising. 5 The skin-bleaching products cur- rently available over the counter are merely a more subtle form of an intractable racism that still exists today. VIEWPOINT Sotonye Imadojemu, MD, MBE Departments of Medicine and Dermatology, Hospital of the University of Pennsylvania, Philadelphia. Autumn Fiester, PhD Department of Medical Ethics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia. Corresponding Author: Sotonye Imadojemu, MD, MBE, Hospital of the University of Pennsylvania, 100 Centrex Bldg, 3400 Spruce St, Philadelphia, PA 19104 (sotonye .imadojemu @uphs.upenn.edu). jamadermatology.com JAMA Dermatology August 2013 Volume 149, Number 8 901 Downloaded From: http://archderm.jamanetwork.com/ by a University of Pennsylvania User on 12/09/2013