A Picture of Health?

: unmasking the role of appearance in health

Annemarie Jutel, Stephen Buetow

Perspectives in Biology and Medicine, Volume 50, Number 3, Summer

2007, pp. 421-434 (Article)

Published by The Johns Hopkins University Press

DOI: 10.1353/pbm.2007.0032

For additional information about this article

http://muse.jhu.edu/journals/pbm/summary/v050/50.3jutel.html

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 A Picture of Health?

unmasking the role of appearance

in health

Annemarie Jutel* and Stephen Buetow†

ABSTRACT Evaluating health requires visual assessment. From the meticulous

self-scrutiny of a worried woman in front of the looking glass to the doctor’s reaction
at the sight of a patient in the examining room, external appearance plays an impor-
tant role in appraising health above and beyond clinical assessment. However, this dom-
inance of the visual in our image-driven culture has assumed a disproportionately
prominent position. Media, businesses, and health care commonly misrepresent appear-
ance as the reality of health. Industry mongers beauty-promoting wares and services as
health-protecting products, and physical appearance contributes to clinicians’ imperfect
heuristics. An explanation for this focus on appearance is persistence of the ancient
belief that looks indicate inner character. In this article we unmask the historical ori-
gin of this belief and reveal how it contaminates contemporary approaches to health
assessment and maintenance.

MAY HAVE THE BODY but of a weak and feeble woman but I have the heart
“I and stomach of a King.” Such apparently were the words of Elizabeth I,
when in 1588 she rallied her troops at Tilbury against the expected invasion by
King Philip of Spain and his mighty Armada (Levin 1994). Her words underline
the need to challenge judgments about character, capacity, and health on the
exclusive basis of appearance, an obligation still present today in popular and pro-
fessional attitudes to health. This is not to devalue the importance of external

* Otago Polytechnic, Dunedin, New Zealand.

† Department of General Practice and Primary Health Care, University of Auckland,Auckland, New
Zealand.
E-mail: ajutel@tekotago.ac.nz.

Perspectives in Biology and Medicine, volume 50, number 3 (summer 2007):421–34

© 2007 by The Johns Hopkins University Press

421
Annemarie Jutel and Stephen Buetow

appearance in appraising health above and beyond clinical assessment, but rather
to qualify that role.
Approaches to defining health include the “biomedical model,” which in an
extreme form views the body as a machine (Capra 1983); the “holistic model,”
which views health as a state of complete well-being (WHO 1948); and the
“wellness model,” which sees health dynamically as a process or force to be pro-
moted (WHO 1986). None of these approaches seems to acknowledge explic-
itly the distinction between what health is and what health appears to be; that is,
none allows for the extent to which the lay and the professional incorporate ap-
pearance in their assessments of health. This article will argue that how people
look, or indeed how people believe people should look, has an important influ-
ence on a number of contemporary health practices by patients and their health
care providers. We argue not for an exclusion of visual inspection from clinical
assessment, but for acknowledgment that cultural norms of appearance surface in
insidious ways in both lay and professional assessments of health.
Many practices are based on the assumption that the appearance of the indi-
vidual provides a portal to the inner self, a glimpse of the hidden workings of
the body.The belief that an outer shell provides evidence of the state of the inner
self is an important concept for understanding the extent to which appearance
is intricately involved in judgments of health. In Confessing Excess, Carole Spit-
zack (1990) refers to an “aesthetic of health.” She describes this as the way that
standards of appearance replace standards of health and are set as proxy targets to
which individual subjects tend unrealistically to aspire. These culturally deter-
mined targets include slenderness in women, as well as “appropriate skin color-
ing, muscle conditioning, facial structure, and an absence of facial lines or ‘defec-
tive’ features.” Seeing this aesthetic as a health goal, she believes, infuses the
manner in which most Westerners now approach their health and their use of
health care. However, based as it is on elusive standards, it fosters a widespread
and pernicious malaise in Western society, which results from meticulous self-
scrutiny, itself an omnipresent preoccupation with the gaze of the other, and a
continuous pursuit of the perfect body, often at the expense of truly health-pro-
tecting and health-promoting behaviors.
But aesthetics also influence clinical decision making. Visual and perceptual
preferences play an important role in medical judgments about the abnormal.Ac-
cording to Stafford, La Puma, and Schiedermayer (1989): “there is an unstated
standard of what is common or average to the species . . . [which is] revealed in
our unconscious response to people who depart measurably from that expecta-
tion.”This unstated standard governs how health care professionals respond to pa-
tients, how the law protects patient rights and what defines our health priorities.
To understand how appearance infiltrates contemporary health practices, we
will first outline how vision and visual images (in this case, how one looks) hold
a dominant cultural position in the range of senses, and how they are conse-
quently accorded a prophetic role in revealing interiority. Second, drawing

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 A Picture of Health?

notably upon the Foucauldian discussion of the gaze, we will “see” how appear-
ance serves as a site of social control by normalizing views of health.We will also
explore associations between health and beauty, and illness and ugliness, in the
ordering of social concerns. Finally, we will explore a range of practices that
emerge from the links between health and beauty and discuss the impact of at-
taching importance to appearance in health care assessment, management, and
consumer behavior.

The Domination of the Visual

Vision is a dominant sense, both in our apprehension of the world and in the
cultural importance we accord to the visual. This can be justified from an evo-
lutionary standpoint:“Vision became more important and olfaction less essential
when men’s ancestors left the ground and took to the trees. . . .Without it, jump-
ing from branch to branch becomes very precarious” (Hall 1966). Standing up
on our hind legs led us to use our eyes like binoculars, writes Diane Ackerman
(1990). Our eyes helped us to pinpoint prey and to detect potential dangers that
might approach us—predators, dangerous precipices, fallen trees. Even though
we no longer use hunting skills to guarantee our survival, our eyes remain our
most important sensory organ. According to Ackerman, 70% of the body’s sense
receptors cluster in the eyes.
Many commonly used words take their root in sight or vision. Martin Jay
(1993) provides a salient example in the introductory paragraph to his book,
Downcast Eyes, where he identifies more than 20 visual metaphors contained in
common words that do not generally refer to sight: vigilant (from the Latin vigi-
lare, to watch), demonstrate (from the Latin monstrare, to show), inspect, prospect, and
speculate (from the Latin specere, to observe), scope (from the Latin, scopium, to look
at), and view, review, and survey (from the Latin videre, to see). While the visual
metaphor does not readily appear on a surface level, these words are potent ex-
amples of how the visual is quietly embedded in the English language, punctu-
ating its importance in subtle and inconspicuous ways.
The infusion of language with visual references goes further than etymology.
The metaphors of everyday speech also emphasize the favoured position of sight
in imparting knowledge. “I’ll believe it when I see it,” “A picture is worth a
thousand words,” or “Enlighten me” confirm a relationship between vision and
truth. Similarly, knowledge and clarity are embodied in visual metaphors.“I see,”
we say when we understand a concept; “What are your views?” we ask when
gathering opinions; and we call someone with original ideas a “visionary.”
Anthony Synnott (1993) points out that “eyewitness” accounts are always held
in higher esteem than “hearsay” evidence.As these metaphors illustrate, sight de-
notes knowledge, truth, reason, and wisdom.

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Annemarie Jutel and Stephen Buetow

Figure 1
Purity: A moral virtue captured here in physical appearance.

Beauty and Virtue

As a result of the power ascribed to vision, appearance—that part of an indi-
vidual which is visually available—confers important symbolic meaning, seem-
ingly offering insight to a person’s true nature. Both popular and religious texts
have long associated beauty with moral goodness, and ugliness with sin and amor-
ality (Figure 1). The heroes and heroines of folk tales are either beautiful or will
become so (Cinderella, Rapunzel, the Frog Prince), while the villains are ugly.
In a fifth-century Traité de physiognomie, the writer linked unattractive physi-
cal features to undesirable personality traits: “people whose breasts droop, and
whose chest is covered with soft flesh are assigned to drunkenness and sexual ex-
cess,”“rounded, and swollen flanks indicate vain gossip—such are just like frogs,”
and “when the ankles, the end of the feet and the heels are fat and fleshy, they
indicate an idiot or a fool . . . and even more so if these very feet have short toes
and large calves.”
In the same manner, courtesy books of the Renaissance confirmed that beau-
ty reflected goodness and ugliness, evil.“Very seldom [doth] an ill soule dwell in
a beautifull bodie. And therefore is the outwarde beautie a true signe of the in-
warde goodnesse,” wrote Baldessare Castiglione (1561, p. 309). Francis Bacon
echoed these ideas 100 years later, when he asserted that “Deformed persons are

424 Perspectives in Biology and Medicine

 A Picture of Health?

Figure 2
Physiognomical assessment of character on the basis of appearance. Philopropogenitiveness =
a propensity to love infants and small animals.

commonly even with nature, for as nature hath done ill by them, so do they by
nature being for the most part (as the Scripture saith) void of natural affection”
(Synnott 1993, p. 88). The back of Leonardo da Vinci’s portrait of Ginevra de’
Benci carries the inscription “Beauty Adorns Virtue” (Brown 2001). Both phys-
iognomists and phrenologists have sought to establish rules linking personality
and social behavior to appearance and form (Figure 2). In his introduction to the
Nouveau manuel (1843), Antoine Pernety declared “everything in nature brings a
distinctive or hieroglyphic sign to the surface by which observers can easily rec-
ognize the secret virtues and properties.” Physiognomy, he continued, is the “ex-
pressive living portrait where nature develops for our eyes the true traits which
characterize each individual in particular. . . [physiognomy] always expresses the
truth and makes it pierce through borrowed colors, dissimulation, the mask of
deception which art seeks in vain to hide” (p. 14).
Beauty and Health
This relationship between good and beauty, bad and ugly provides a founda-
tion for the relationship between appearance and health. Over the course of the
19th century, modifications in conceptions of virtue established health as de-
pendent on, and indicative of, beauty. Elise Voiart (1822), writing in a handbook
for young girls, expressed these connections:“a well-ordered life; gentle and var-
ied occupations, the exercise of virtues, with the interior joy which is its most
precious reward . . . are the causes which maintain the flexibility of the organs,
the free circulation of the humors, the perfect state of all the functions from

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Annemarie Jutel and Stephen Buetow

which issues health, without which beauty cannot exist” (p. 67). By the end of
the 19th century, discussions of beauty had shifted from considering health as an
important partner of virtue to dropping discussions of virtue in favour of health
alone. Dr. Ernest Monin, in L’hygiène de la beauté (1886), wrote that “to have a
beautiful face, you must first have beauty of the soul and of the heart, joined with
perfect physical health. See how organic suffering contracts the lines of the face,
reddens and pales the skin! See how hate and bad thoughts, with a vile soul, take
away from the face, bit by bit, its laughing serenity, its open frankness and its re-
freshing sympathy” (p. 76).
This fin de siècle change in the tone of the discussion in both moral and beau-
ty texts about what the body represents also includes ideological explanations of
physiological function. For a group of American Christian hygienists, excessive
digestive stimulation could lead to congestion of the pelvic organs which in turn
could lead to “solitary vice” or masturbation. Preventing this scourge hinged on
dietary modification; monitoring it was based on visual scrutiny of a young per-
son’s appearance. John Kellogg (1901) emphasized visual monitoring for telltale
signs of flagging morality. One could suspect masturbation, for example, by the
presence of acne. “Pimples upon the face,” he wrote, “especially when appearing
upon the forehead as well as upon other parts of the face, are strong evidences of
irritation of the sexual organs, produced by self-abuse” (p. 380).

Social Control, Appearance, and Health

Appearance is a powerful tool in social control, and understanding the role of
appearance is fundamental to our understanding of the relationships between ap-
pearance, morality, and contemporary angst. Seeing, being seen, or simply being
at risk of being seen creates an internalized form of constraint that makes peo-
ple adhere to social rules.1
Appearance is not alone in controlling behavior. Health, illness, and their
management also exercise control and impose structure on individuals and soci-
ety. As I. K. Zola (1972) notes, medicine plays an important role in managing
society, by what it decides to treat, whom it decides to circumscribe, and where
it decides to place responsibility. Zola describes the power of the use of medical
rhetoric and evidence in the arguments to advance any cause: “The prestige of

1 Foucault (1977) theorized that control through the visual operates like the Panopticon, an 18th-
century prison design consisting of a central viewing tower placed in the center of a round or semi-
circular prison, where guards could view the inmates at any time while being concealed themselves
by backlighting. In the Panopticon the inmates’ actions are potentially—rather than actually—vis-
ible, which constrains them to their jailers’ expected behavior.The principles of visibility and con-
straint captured by the Panopticon are the mechanism by which individuals internalize social ex-
pectations. The potential to be seen at any time moderates not only what one does, but also how
one wants to look and be regarded.

426 Perspectives in Biology and Medicine

 A Picture of Health?

any proposal is immensely enhanced, if not justified, when it is expressed in the

idiom of medical science” (p. 496).
When appearance and illness combine, they become powerful motivators for
conformity, producing docile subjects who are subservient to social mores. Self-
scrutiny involves vigilant monitoring of those visual signs of poor health that are
believed to be due to negligent self-maintenance: for example, inadequate exer-
cise, poor eating habits, insufficient hydration, lack of discipline.

Peddling Potions and Mongering Meds

The health-equals-beauty discourse pervades contemporary media, markets, and
health practices. From body size to skin tone or muscle definition, a range of
products and regimens that purport to offer consumers a better look and better
health are available. Diets, exercise programs, tone equalizers, nutritional supple-
ments, and mineral waters are a small sample of these products. Looking good,
through being healthy, sells.
Body size is perhaps the most flagrant example of the contemporary confla-
tion of appearance with health. Despite evidence that the Body Mass Index is an
unreliable predictor of body fat and a poor measure of overweight, that over-
weight individuals who have healthy diets and regular exercise patterns have less
morbidity and mortality than thin individuals who don’t, and that the risk of
weight loss in overweight people may be greater than the risk of the excess
weight, weight reduction, muscle tone, and body shape are exceptionally strong
markers of “health” to both consumers and health professionals (Buetow and
Docherty 2005; Gaesser 1999; Lee, Blair, and Jackson 1999; Nevill et al. 2006).
Careful tracking of patient weight, admonishments to reduce weight in the pres-
ence of weight creep, and pride in weight loss regardless of cause, are all preva-
lent in approaches to health maintenance.
“Looking fantastic. Feeling great!” heralds the Contours Women’s Gym.
“Whether you’re searching for a new body—or just a balanced life—we’re here
to help.” The gym promotes health “shaping up” and “seeing what [you’ve]
achieved,” and focuses on centimeters lost and weight goals achieved.The gym,
which prides itself on its woman-friendly approach to fitness, confides,“there are
certain elements of our bodies that we might like to change, and with just a lit-
tle effort we can. At Contours, we can change your fitness, improve you with a
firmer toned body.” Fitness and body shape are linked and indeed conflated; the
appearance of the body reveals its internal state of wellness. By suggesting that
this change in the shape of the body will “improve” women, Contours perpet-
uates historical mythologies about the connection between appearance and the
self. Interestingly, Contours also markets sunbeds and hair and beauty services
under the guise of health and fitness.
A number of beauty products use the idea of “feeling well” as marketing tools.

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Annemarie Jutel and Stephen Buetow

Clinique, for example, offers “prescriptions” for perfect skin, because “the Cli-
nique System gives any age skin what it needs to look and feel its best.” Beauty
makes us feel better.
On the other hand, advertising for Neutrogena Daily Moisturizer with sun
block uses the incentive of physical beauty to engage consumers in a legitimate
health practice.While the discreet American Cancer Society stamp reminds us to
“help block out skin cancer,” the advertising copy focuses on appearance to sell
its health-protective product. The marketing points out that this product pro-
vides protection against sun “damage” that can cause up to 90% of the signs of
aging—which are presumed to be unappealing to the consumer.
Appearance not only drives the consumer through the explicit look-good-
feel-good discourse, the use of beautiful people to market health also infuses
consumer marketing strategies. In an advertisement for milk, model Elizabeth
Hurley sprawls in the sand, her hair artfully arranged, arms coquettishly raised,
breasts invitingly round, and milk mustache on her upper lip.“Hot mama” reads
the accompanying text. Hurley is quoted as saying: “I want to look great and
milk helps. Studies suggest that people who drink milk regularly tend to weigh
less and have less body fat than those who don’t.” An hourglass-shaped vessel
filled with milk nestles in the bottom corner of the page with the caption “Milk
your diet. Lose weight.”While the Website associated with this promotion indi-
cates the nutritional content of milk and its role in the prevention of osteo-
porosis, the focus and message of the site is the great American Weight Loss
Challenge (2006). Here, the reader is invited to “look great,” prompted both by
the carefully chosen, attractive model and by the rationalization that science
(“studies suggest”) has made this avenue valid and necessary. References to the
studies are buried in a back page of the Website, and are of dubious quality, be-
cause the studies have been replaced by summaries prepared and annotated by
the National Dairy Council, whose commercial interest is, of course, to promote
milk products. The advertisement places more emphasis, and more visibility, on
the social approval than the scientific: Hurley and other attractive models are
hot—beautiful people do this.
Beautiful people remind consumers of their own shortcomings—and potential.
Advertisements for a range of products depict the people we’d like to be: white-
clad middle-aged couples with windswept hair frolicking on the beach with
plaque-free arteries (COCOAVIA); dynamic perky, flat-abbed gym bunnies sitting
crossed-legged in running bras without the high blood pressure, heart disease,
impaired memory and depression that results from a poor night’s sleep (Tempur-
Pedic); and hot, sexy lovers cavorting without fear of herpes (FAMIVIR). Our
attraction to these products lies in the hope that if only we didn’t have the heart
disease, or high blood pressure, we too would resemble—at least a little bit more—
these icons.

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 A Picture of Health?

Ugliness and Illness

Strongly embedded in the beauty-health relationship is an important corollary:
illness is an ugly thing, and it can be visually assessed. Sander Gilman’s (1995)
work on the use of images of health and illness focuses on how deviant appear-
ance was cast as illness in historical medical texts: the diseased is not only the
ugly, but the ugly is the diseased. And the ugly must be made to give way to the
beautiful through the agency of scientific medicine. What is desired is a world
peopled by the beautiful, and only an absolute norm of beauty is permitted.
In this case, however, beauty is not in the eye of the beholder, but rather in
the cultural norms of the dominant social group. In Western medicine, accord-
ing to Gilman, the “normal Aryan” provided the referent from which deviance
could be assessed. Jewish and black bodies, he writes, were the model for the ugly
and the diseased. The Jewish nose was not only a marker of race, but of defi-
ciency and pathology.Today, racial deviation from aesthetic norms still occasions
concern. For example, Catherine Padmore (1998) relates the dominance of fair-
skinned, blond-haired models in Western fashion media to attempts by Asian
American women to emulate the “occidental” eye through surgical as well as
non-invasive means. This “Westernizing” correction of appearance ostensibly
alleviates anxiety and enhances self-confidence in a population of women who
are Other to the visual norm within a racist sociopolitical structure.
That ugliness is cast as an illness also takes root in 20th-century reconstructive
plastic surgery.According to Elizabeth Haiken (1997), the emergence of this med-
ical specialty was predominantly related to the repair of congenital and traumatic
injury, notably in relation to the disfigurement of returning servicemen after the
First World War.While there was a growing market for the cosmetic use of plas-
tic surgery, its use to correct minor aesthetic defects was an ethical challenge to
some surgeons, one of whom wrote that he felt resentment at “being called on to
belittle our profession by catering to the vanities in frivolities of life” (p. 93).
Haiken argues, however, that the deep urge for self-improvement reframed
the importance accorded to the perfect appearance. If social and professional sta-
tus was a competitive matter, to be won at great cost, then looking as good as
possible was also part of the equation. And, in this context, believes Haiken, not
having access to socially sanctioned looks was less a matter of disfigurement than
a source of psychological distress. The “inferiority complex” was the operative
concept. Haiken explains:

The inferiority complex, in fact, became the final link in the self-reflexive argu-
ment plastic surgeons formulated to justify the practice of cosmetic surgery.
Patients who developed inferiority complexes because of physical defects would
find their economic status adversely affected, because those suffering from such
complexes were unable to present themselves with the confidence necessary to
ensure success in a competitive world. (p. 94)

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Annemarie Jutel and Stephen Buetow

Each era has its normative ideal of beauty, and the athlete’s trim figure holds
particular sway in the early 21st century, as do the features of the blond Cau-
casian female. And flaws reveal moral imperfections: our thighs could be trim-
mer, our triceps tauter “if only” we were more vigilant about diet, more assidu-
ous in exercise. Campos and his colleagues (2006) describe an ideological
commitment in the focus on “individual responsibility” that draws attention
away from structural factors that continue to drive health care costs upward and
leave many Americans without health care coverage of any kind.

Implications for Health Care

We know that the media, businesses, and lay people misconstrue appearance to
represent health. Should we presume that the health care professions are differ-
ent? For us, this would be a mistake.The same values that motivate patients affect
health care practitioners. Even if we could argue that the health professions have
the ability to critically evaluate these value-laden practices, they still have to
manage the laity with its set of beliefs. To conclude, then, we will examine the
ways in which appearance surfaces in the health care setting, in both clinician
and patient behaviors.
Appearance is assessed via gaze, and Foucault has provided an in-depth analy-
sis of the medical gaze in his Birth of the Clinic (1973). The gaze helps to uncover
the truth of the body, with the physician’s eye a source of reality. While the pa-
tient’s account may mask and mislead, the physician seeks to observe, examine,
scrutinize, and inspect, trying as he or she might to reduce subjective noise. Fou-
cault describes the clinical encounter as the encounter of the active eye and mute
body—enclosed in a common but not-reciprocal situation. He quotes Sournia’s
explanation of the logic of diagnosis: “we observe patients in the same manner
that we observe the stars,” he writes, “or a laboratory experience.”
But if we rely upon the trained eye, we must not, as Barbara Stafford and her
colleagues (1989) remind us, neglect the role of the private beliefs of physicians
regarding proper appearance. Like their patients, physicians consciously and sub-
consciously marginalize those visual features that depart measurably from norma-
tive and idealized expectations.We will again use fatness as a convenient example
for demonstrating the extent to which deviance from idealized norms influences
physicians, as well as medical policy, public health agencies, and the public.
The response to fatness is unequivocal and uniform: it is bad to be fat. Just as
readily as lay people, health professionals make judgments about their patients on
the basis of their size alone, and anti-fat stigma is strongly present in the health
care setting. A study of physicians’ automatic response to their obese patients
found that physicians thought these patients were bad and lazy (Hebl and Xu
2001).The heavier the patient appeared, the more the doctors thought the con-
sultations were a waste of time, the less tolerant they were in dealing with client
issues, and the more annoying they found the patient. They also believed that

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 A Picture of Health?

heavier patients were less compliant. Puhl and Brownell (2003) pointed out that
the consequences of anti-fat stigma may contribute to increased weight gain,
through the withdrawal and social isolation created by the presence of a visual
marker (fatness) symbolizing ill-discipline.
The common argument is that fatness indicates gluttony and sloth. This is a
flawed argument. Campos and colleagues (2006) point out that body weight,
“like height or baldness, is for the most part a proxy for many unmeasured vari-
ables.”Yet most public health campaigns and obesity policies presume that fat-
ness reflects poor activity levels and diet, while thinness accompanies a healthy
lifestyle.
The National Institutes of Health algorithm for the management of over-
weight and obesity, for example, seeks to quantify the patient’s fatness but only
considers dietary therapy, behavior therapy, or physical activity in the patient
whose Body Mass Index indicates overweight or obesity (NIH 1998). The algo-
rithm advocates no exploration of the patient’s dietary or exercise habits; it relies
instead upon weight as a screening tool and suggests making no recommenda-
tions about lifestyle or diet to the thin patient. Campos et al. (2006), however,
argue that lifestyle and dietary modifications entail many more health benefits
than weight loss alone, ranging from improved lipid profile, reduced blood pres-
sure, and improved insulin sensitivity, to lifestyle and dietary modification, even
in the absence of weight loss.As we have noted above, Lee and colleagues (1999)
add that thin men with poor diet and exercise patterns have higher morbidity
and mortality than obese men with healthy lifestyles. Ironically, looking good
may be more dangerous than looking fat.
Body size is not the only aspect of appearance critically present in the clini-
cal encounter. Welie (1999) unpacks the notion of ugliness as an indication for
dental treatment. Is delivering a “healthy smile,” he queries, a legitimate medical
intervention if it enhances the social status of the individual who requests it?
Where do we draw the line between restoration of normality and vain enhance-
ment? He points out, as did Haiken, that plastic surgeons have used clinical psy-
chology as a way of creating medical justification for what we may legitimately
consider enhancement rather than medical treatment. As Welie indicates, how-
ever, drawing the line is a difficult matter. Many would agree that correction of
appearance in some instances can be intrinsic to a patient’s psychological well-
being.
Nonetheless, health professionals need to think carefully about how they as-
sess their patients when they arrive for a health care encounter “looking good.”
Do these patients’ beliefs, and those of the doctors—in a fashion-magazine,
youth-oriented cultural environment—mislead? The majority of university stu-
dents in one study believed that a tan makes them look healthy, concern about
weight gain is a common barrier to smoking cessation, and exercise enthusiasts
may focus more on looking healthy than on being healthy, using a range of
potentially dangerous drug and dietary regimens to achieve a healthy look

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Annemarie Jutel and Stephen Buetow

(Levine, Perkins, and Marcus 2001; Monaghan 2001; Pomerleaua et al. 2001;
Young and Walker 1998).
These beliefs do mislead health professionals. As Kreuter et al. (1997) point
out, physicians tend to use “imperfect heuristics” to determine what to advise
patients, relying on corpulence, for example, to prompt advice about physical
activity and diet, regardless of patients’ current diet or exercise patterns, while
neglecting to give such advice to slender patients. Similarly, as one of Mona-
ghan’s (2001) respondents reports:“And going to my doctor, he says,‘well you’re
fit!’ despite his reliance on steroids to achieve the appearance his doctor lauded.
Whilst no heuristic is faultless, it is useful for clinicians to reflect on the assump-
tions underpinning their recommendations and to acknowledge how appearance
influences practice.
This is not to say that appearance should be ignored in the health encounter.
Numerous clinical findings are available to the physician’s gaze with more imme-
diacy and saliency than could be assessed by other means, including such impor-
tant markers as erythema, pallor, jaundice, capillary refill, pupil reactivity, swelling,
desquamation, and alopecia. Even phenomenological states can be visually
assessed to some degree in many circumstances. Few physicians would want to
neglect visual evidence of pain, anxiety, distress, or exhaustion. Indeed, appearance
can speak more loudly than words in instances where words fail, and physical
symptoms are prominent and present.
This article has not intended to denigrate the importance of visual assessment.
What we have attempted to bring to the fore is the challenge of recognizing that
appearance is not always as useful an indicator of health or character as main-
stream cultural values promote it to be.As evidenced by the historical material we
have reviewed, this misconception is longstanding, even if its specific form has
varied with the era.We hope to have shown how distortion and overvaluation of
the insights afforded by appearance may harm medical practice and policy.
As Stafford and colleagues (1989) write:

physicians ought to become aware of their conceptions of beauty and perfec-

tion. Studying aesthetic values would help medical students recognize the role
these socially conditioned conceptions of beauty play in their perception, treat-
ment and diagnosis of the sick. More importantly, it would assist students in
confronting their intertwined visual, emotional and ethical reactions to the
blemished, deformed, and abnormal patients that will constitute daily medical
practice. (p. 228).

Clinical decision making is complex and relies upon a range of cognitive mod-
els, the understanding of which is important to effective diagnosis. Pat Croskerry
(2002) agrees that an important first step in diagnosis starts in the visual, in the
pattern recognition that sets the frame for the work-up that follows. But it can
also lead to anchoring bias, or a tendency to focus on a first impression, and to
prematurely closed diagnostic options.

432 Perspectives in Biology and Medicine

 A Picture of Health?

Values are a complex component of health care that professionals must con-
sider as carefully as they do the research evidence upon which they are encour-
aged by evidence-based medicine to make treatment recommendations. There
are flagrant as well as subtle infusions of cultural meaning in the assessment of
health and illness.

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