JSUR Journal

Background

The landscape of plastic surgery has undergone a significant transformation in recent years, with a growing emphasis on cosmetic procedures alongside its established role in reconstructive surgery. Several factors have contributed to this evolution, including scientific advancements in medicine, shifting beauty standards, and the undeniable influence of social media [6,7]. nitially, plastic surgery focused solely on reconstructive procedures, aiming to repair injuries caused by accidents, burns, or birth defects. However, as surgical techniques improved and safety standards rose, the field expanded to encompass cosmetic alterations for aesthetic purposes [8]. This trend has been further fueled by the commercialization of beauty, where cosmetic surgery is increasingly seen as a means to enhance self-worth and social standing [7]. The rise of social media platforms like Instagram, TikTok, and YouTube has further propelled the popularity of cosmetic surgery [9]. These platforms provide new avenues for surgeons to market their services and educate potential patients, while simultaneously shaping public expectations.

However, the ethical implications of showcasing plastic surgery procedures on social media raise concerns. While these platforms offer opportunities for education and empowerment [10], the portrayal of idealized outcomes and minimized recovery times can create unrealistic expectations and potentially downplay the inherent risks involved [11]. The surge of hashtags and social media campaigns has revolutionized the way plastic surgery is perceived and marketed. Studies have shown that hashtags on Instagram serve a dual purpose: educating the public and promoting cosmetic procedures [12]. However, the constant bombardment of “perfect” results and unrealistic recovery timelines can lead to misconceptions and encourage individuals to pursue surgery without fully comprehending the potential risks and long-term consequences.

Social media’s influence extends beyond marketing; it also impacts patient behavior and expectations. The ease of access to countless before-and-after photos and patient testimonials can create a sense of urgency and a desire for immediate results [11]. This has triggered ethical concerns regarding informed consent and the potential for exploitation, particularly in the context of non-surgical cosmetic procedures where patients may be pressured into more invasive surgeries without fully understanding the implications [9]. Technological advancements have also played a crucial role in the development of plastic surgery. Advances in surgical techniques, anesthesia, and related procedures have made these interventions safer and more accessible for a wider population [13]. Minimally invasive procedures like laser surgery and injectable fillers offer faster recovery times compared to traditional surgeries, further adding to their appeal for patients of all ages, including younger demographics seeking cosmetic enhancements [9]. One such example of media integration in plastic surgery is the collaboration between the American Society of Plastic Surgeons (ASPS) and the television show “Extreme Makeover.” Initially hesitant about the partnership, the ASPS ultimately agreed to participate but insisted on stricter ethical guidelines, including patient discussions, informed consent, and thorough pre-surgical evaluations (American Society of Plastic Surgeons, 2024).

The introduction of social media as a tool for marketing and education has undoubtedly shifted the paradigm of plastic surgery, impacting patient behavior and expectations [14]. It is crucial to ensure that these practices adhere to strict ethical standards to maintain the integrity of the profession and prioritize patient safety.

Ethical Considerations in Plastic Surgery Marketing

The ethical landscape of cosmetic surgery marketing is complex and multifaceted. It’s crucial to examine this landscape through the lens of patient autonomy, beneficence, non-maleficence, and justice [15]. Patient autonomy, or the right to make informed choices, is often compromised by misleading marketing tactics [2,3,16]. Regulatory measures should prohibit deceptive campaigns and ensure truthful marketing materials. Informed consent is critical. Patients must fully understand the nature of procedures, including potential risks and benefits (Aquino, 2017) [17]. However, marketing materials often prioritize benefits while downplaying risks. Regulations should mandate clear risk and benefit disclosures, comprehensive communication about treatment options, and documentation of patient discussions to ensure informed decisionmaking [18]. The principle of justice calls for fairness in healthcare delivery. However, the commodification of beauty in cosmetic surgery can lead to the exploitation of vulnerable populations [7,8,19]. Marketing practices targeting individuals with low selfesteem or body dysmorphic disorder raise serious ethical concerns [11,14,20].

Social Media and Unethical Marketing

The rise of social media has significantly impacted the marketing of cosmetic procedures. While it offers a platform for surgeons and clinics to showcase their services, ethical concerns arise due to the blurring of lines between promotion and professionalism [21]. Hashtags like plasticsurgery and aesthetic surgery can be helpful for raising awareness, but they also contribute to the commercialization of these procedures (Ghigi et al., 2021). Often portrayed as simple solutions, these complex medical interventions can lead to unrealistic expectations and decisions based on idealized outcomes rather than informed consent [16]. Influencer marketing has emerged as another trend, with surgeons or clinics partnering with social media influencers to reach potential patients [22]. While this can benefit some, ethical issues arise regarding information disclosure and credibility. Promotional content may distort the potential dangers and complexities of surgery, making it seem more beneficial than it is in reality [23]. The increased use of social media marketing and persuasive digital content can make it difficult for patients to understand the risks and recovery times involved in cosmetic procedures (Atiyeh et al., 2022). Misleading information and idealized beauty standards can compromise informed consent, a cornerstone of ethical medical practice [24].

The Need for RegulationLaying down ethical regulations for marketing cosmetic procedures iscrucial to ensure ethical practices and consumer protection [25]. These regulations should address misinformation, unrealistic beauty standards, and the exploitation of vulnerable populations (Atiyeh et al., 2022). Marketing content needs to be realistic and avoid misleading portrayals. It should highlight both the benefits and potential harms of procedures without exaggeration [18]. Additionally, promotions shouldn’t target vulnerable groups like teenagers or individuals with body dysmorphic disorder [20].

Professional standardsrequire regulatory bodies to establish strict rules regarding who canadvertise cosmetic surgery [26]. Only qualified and licensed professionals should be allowed to advertise these procedures. Existing guidelines by the American Society of Plastic Surgeons (ASPS) and the General Medical Council (GMC) [27] emphasize honesty and patient well-being [28]. However, the lack of regulations specifically for social media marketing creates a gap that needs to be addressed.

Developing specific guidelinesfor social media is necessary to address issues like influencerinvolvement, photo editing, and the advertising of off-label uses [29]. Ethical regulations for cosmetic surgery promotion on social media should focus on:

• Maintaining integrity in advertising: This involves avoiding misleading claims and ensuring transparency.
• Reducing appeals to vulnerable clients: Protecting vulnerable populations from exploitation is crucial.
• Preserving the integrity of the profession: Upholding ethical standards within the field is essential.
• While general recommendations exist, social media marketing requires more specific guidelines due to its complexities [29].

Ethical Concerns and Legal Issues

The rapid evolution of marketing practices and social media use in cosmetic surgery has led to new ethical and legal concerns (Atiyeh et al., 2022). These concerns revolve around informed consent, disclosure, content quality, and potential exploitation (ibid.). One key challenge is ensuring informed consent, a fundamental principle in medicine requiring patients to understand the risks and benefits of a procedure before deciding [17]. Marketing on social media may present a one-sided picture, neglecting or minimizing potential negative effects (Atiyeh et al., 2022). Regulations should promote transparency and ensure all promotional information accurately reflects the procedures. Another concern is the reliability of information presented in advertisements. Social media’s potential to mislead patients due to editing and idealized portrayals of procedures is significant [30]. While social media can be an educational tool, it’s crucial to ensure the accuracy of all marketing information [31]. Predatory marketing tactics that exploit vulnerable clients with low self-esteem or body dysmorphic disorder are unethical [19]. Ethical marketing practices should not take advantage of patients’ vulnerabilities for profit.

A further issue arises when surgeons decline procedures due to personal beliefs or ethical principles, leading to a conflict between patient rights and healthcare professional ethics [32]. Surgeons need to navigate this conflict carefully, ensuring their beliefs don’t infringe on patients’ legal right to seek medical services. Balancing patient autonomy with clinician professionalism

Doctors’ Roles and Responsibilities in Addressing Ethical Dilemmas

In recent years, there has been a growing emphasis on the ethical challenges inherent in plastic surgery, driven by the recognition of complex dilemmas that practitioners encounter in their daily practices [33]. While ethical considerations are acknowledged, they often receive insufficient attention, highlighting the need for a structured framework that prioritizes patient welfare. Central to this framework is the principle of patient autonomy, which emphasizes the importance of informed consent, enabling patients to actively participate in decision-making by understanding the risks, benefits, and alternatives associated with their procedures [34].

The principle of beneficence requires surgeons to balance aesthetic desires with safety, often navigating procedural conflicts where the benefits of a procedure may be unclear [10]. Additionally, nonmaleficence is critical in cosmetic surgery, as procedures carry inherent risks [35]; thus, surgeons must minimize these risks through diligent planning, adherence to established protocols, and thorough pre-operative evaluations. The principle of justice further underscores the need for equitable access to healthcare, prompting plastic surgeons to advocate for fair insurance practices and address disparities faced by marginalized populations [36].

Ethics in plastic surgery extends beyond principles; it involves a lifelong commitment to reflection, learning, and engagement in ethical practice amid emerging challenges [36] mentorship, and participation in organizational development programs are essential for cultivating ethical expertise. Practitioners are encouraged to engage in self-reflection to assess the broader implications of their decisions on individuals and society. By employing frameworks such as Beauchamp and Childress’s, surgeons can enhance their ethical decision-making, ensuring that patient welfare remains central to their practice [37].

Regulatory Frameworks for Cosmetic Surgery and Advertising Standards

Strong advertising regulations are crucial for building trust with potential patients, minimizing the risk of misleading claims, and promoting informed decision-making about cosmetic procedures [38]. Ethical and moral principles in advertising also contribute to public health and safety [39]. These advertising standards vary by jurisdiction due to differences in cultural, ethical, and legal systems.

Advertising Regulations Around the World

United Kingdom: The Advertising Standards Authority (ASA) enforces strict rules for advertising cosmetic surgery and other treatments. These regulations ensure that advertisements are legal, truthful, and avoid exaggerated claims, unsubstantiated efficacy statements, or unrealistic portrayals of results [40]. The General Medical Council (GMC) [27] sets additional standards for doctors advertising cosmetic procedures. These standards require doctors to avoid misleading information, ensure the information is credible and informative, and refrain from using patient testimonials for endorsements [41]. The GMC also has specific policies to prevent targeting vulnerable populations like adolescents and individuals with body dysmorphic disorder [42]. Additionally, advertisements cannot exploit patients’ insecurities or suggest that cosmetic procedures will dramatically improve someone’s life professionally or personally. All claims regarding efficacy must be supported by robust clinical evidence (Abelsson & Willman, 2021).

Global Regulations: Regulations for cosmetic surgery advertising differ across countries. In the United States, the Federal Trade Commission (FTC) and the Food and Drug Administration (FDA) manage these regulations. The FTC focuses on preventing false and misleading information, while the FDA regulates information related to the safety and efficacy of medical devices and treatments used in cosmetic procedures [43]. The European Union (EU) advertising laws are determined by EU Directives through the General Data Protection Regulation (GDPR) and are further regulated by individual member states [44]. These regulations require advertisements to provide rational information about potential risks, expected results, and potential side effects of cosmetic procedures. Recent changes in France and Germany aim to strengthen informed consent measures and patient information disclosure in response to concerns about deceptive marketing practices that have harmed patients [45]. Germany has particularly strict regulations, even banning the use of “before and after” pictures on social media or other marketing channels [46]. These regulations aim to prevent false claims about cosmetic procedures and protect patient confidentiality.

The Australian media and advertising landscape is governed by the Australian Health Practitioner Regulation Agency (AHPRA), which prohibits misleading advertisements and requires all advertising to be evidence-based and free from propaganda [47]. Specific guidelines also prohibit testimonials and require all claims regarding benefits to be scientifically supported. Regulations in Asia vary widely, with South Korea and Japan having strong frameworks while others have weaker ones. Research suggests that South Korea’s strict approach, which coincides with its position as a global leader in cosmetic surgery rates and openness, includes specific government regulations on advertising and consumer awareness campaigns to protect patients and the industry [37]. However, research on legal frameworks in Southeast Asia suggests that weak enforcement and low public awareness contribute to higher levels of unethical marketing and medical tourism fraud [48-60].

These examples highlight the international effort to regulate cosmetic surgery advertising to protect consumers and ensure ethical practices within the industry.

Her in the state of Qatar, In April 2024, the Department of Healthcare Professions (DHP) in Qatar issued guidelines emphasizing ethical advertising practices for healthcare providers, reflecting cultural and religious values. The DHP’s role is to ensure compliance among practitioners to maintain organizational accountability, protect patients, and ensure data safety. Key regulations include:

Advertisements must uphold professional ethics to insure Professional Dignity , respecting Ethical Cultural Sensitivity advertised Content must respect Islamic culture and societal norms , sharing Accurate Credentials: Practitioners must accurately represent their credentials as recorded by the DHP, Only clinical or surgical privileges granted by the DHP may be advertised , Facilities can only advertise regulated health services using approved equipment , Images and videos of patients cannot be used without consent , Unauthorized access to patient data is prohibited, ensuring de-identified data remains confidential , Filming patients during surgery or anesthesia for promotional purposes is forbidden without consent , Advertisements must adhere to Qatar’s copyright laws & All social media content must be approved in writing by both the medical director and the practitioner involved. These guidelines issued aiming to ensure safe, ethical, and culturally appropriate advertising practices in the healthcare sector [61-96].

Discussion

Current regulatory frameworks are not very effective, though their stringency differs across regions, and enforcement is often a problem. The GDPR in the EU and very strict rules regarding advertisements in South Korea are examples of effective regulation [97-100].

However, due to the dynamic nature of digital marketing, there is always a need to review the legislation to safeguard consumers. They should consider the reality that there is a need for cooperation among countries and the development of flexible legal requirements that would be able to respond to the new tendencies in marketing. This paper has argued that through advocating for transparency, increased regulatory measures, ethical marketing, and awareness, the industry can protect the patient’s interests and embrace the highest standards of care. The steps towards solving the ethical issues involved in the marketing of cosmetic surgery include the following: the use of mandatory disclosures in advertisements, conducting of regular audits, and public education [101-120]. Finally, the study shows the need to consider the commercial aspect of services while upholding the ethical standards of the profession. The study also recommends that appropriate ethical standards in marketing and proper legal requirements should be implemented to prevent harm to consumers and to promote responsible marketing. As the forms and techniques of digital marketing are constantly changing, it is crucial to monitor the situation and maintain ethical standards in the sphere of cosmetic surgery [121-129].

Conclusion

Self-regulation of marketing techniques and social media involvement in plastic surgery and cosmetic procedures is vital in ensuring patient protection, professionalism, and ethical best practices. This dissertation has explored different facets of this complex topic, including the role of ethical standards, legal frameworks, and the effects of contemporary marketing strategies on patients and the medical profession. One of them has been the ethics of decision-making in the field of plastic surgery. The concepts of autonomy, beneficence, non-maleficence, and justice are essential in safeguarding patient interest. Respect for persons is especially valued through informed consent and the patient’s right to autonomous decisions involving procedures. By maintaining these principles, patient’s autonomy is valued, and their interests are protected and promoted when coming up with decisions to be made. The dissertation also focused on body image distortion and its psychological implications; I have stressed the importance of the ethical obligation of plastic surgeons to the psychological ramifications of cosmetic surgery. Surgeons should meet patients’ expectations while also considering whether those expectations are healthy for the patient’s mental well-being. Ethical issues are important here, with patients’ vulnerability, and advertisers should not take advantage of this by using fear or false hope. This not only undermines the patient’s right to self-determination but also violates the principle of non-maleficence. Availability and fairness in plastic surgery were discussed, with an emphasis on the fact that surgeries should not be motivated by the possibility of gaining profit but should be available to everyone in need. The objectification of the body and services present in plastic surgery is a crucial source of ethical concern, given issues of motivation and clients’ vulnerability. The adoption of fair practices aids in transforming the beauty and reconstructive surgery field in the right direction of equality. It is also evident that advertising standards have a significant influence on the general ethical standard. In the United Kingdom, the ASA and GMC guidelines are rigid as they want advertisements to be truthful and not misleading in their communication of risks and benefits. This regulatory approach helps consumers avoid being swayed by misleading adverts and helps them make better decisions. However, this is not uniform globally. Overall, the supervision of ethical standards in marketing strategies and in the utilization of social media regarding plastic surgery and other cosmetic procedures is critical in safeguarding patient interests, ensuring appropriate patient decision-making, and upholding the standards of medical practice.

The findings of this study have several implications for future research and policy development. Further research could investigate the effectiveness of different regulatory approaches in various cultural and regulatory contexts. Understanding the diverse impacts of marketing practices can produce more effective and culturally sensitive regulatory strategies. Policymakers should consider the dynamic nature of digital marketing when developing regulations. Continuous updates to regulatory frameworks are necessary to address the evolving challenges posed by new and rapidly expanding marketing strategies. International collaboration is crucial to developing comprehensive rules that can effectively protect consumers across different jurisdictions.171 A coordinated global approach can enhance the effectiveness of regulatory measures and provide a consistent standard for ethical marketing practices. The cosmetic surgery industry should adopt a more ethical approach to marketing, prioritizing patient welfare over profit. Implementing ethical guidelines and promoting transparency can enhance the credibility of the industry and protect consumers from potential harm.172 By committing to ethical standards, the industry can build trust with consumers and contribute to the overall improvement of healthcare quality.

Acknowledgment

We would like to acknowledge the significant contribution of the Dissertation in Law Programme of Study: Medical Law and Ethics, Exam Number: B221141, titled “‘From an ethical perspective, how should we regulate the use of current marketing practices and social media in plastic surgery and cosmetic procedures?’”. This dissertation provided valuable insights and information that significantly contributed to the development of this work.

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