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Editorials
A change in the make-up of medicine
Trevor J Mudge and Dorothy Dashwood
MJA2002; 176 (12): 569-570
Ethics and putting the patient first are the primary considerations
in deciding what is acceptable advertising of medical services
by doctors
Type "cosmetic surgery" into your Internet search engine
and several hundred thousand sites will appear. All enthuse about
the benefits and increasing popularity of their techniques. They
identify and detail medical practitioners qualified to work their
miracles on the human body. Few negatives are to be found in such
promotional material, and much of the hype is not dissimilar to
that used to market other lifestyle products. This is but part
of the global rise of the entrepreneurial approach to healthcare.
Cosmetic surgery is in demand because of the changing culture
and attitude of patients. For some in today's world there is a
need to satisfy a desire for what, in times gone by, would be
unrealistic expectations — changes to their bodies to enhance
their appearance — at least in their own eyes.
If we take the definition used by the New South Wales Committee
of Inquiry into Cosmetic Surgery, "cosmetic surgery"
is any cosmetic procedure "performed to reshape normal structures
of the body or to adorn part of the body, with the aim of improving
the consumer's appearance and self-esteem". It "is initiated
by the consumer, not medical need", and "excludes reconstructive
surgery".1 This lies outside the traditional boundaries of
medicine, which saw the profession dedicated to saving lives,
healing and promoting health.2 Cosmetic surgery is not rebatable
under Medicare, nor covered by health insurance. There are relatively
few referrals. However, it does provide a service for which consumers
are prepared to pay.
Traditionally, the medical profession has prohibited advertising
in its codes of ethics. The traditional view is that doctors should
develop a reputation for excellence based on a reputation among
their peers, rather than by the advertising of their services
directly to the public. This minimises the opportunity for patients
to be misled by claims of superiority of a technique or individual.
Particularly in Australia and the United Kingdom, general practitioners
have long been "gatekeepers" to specialist services.
This role has helped maintain quality care for patients and has
probably helped to contain overall costs in the healthcare system.
But with the demise of paternalism, both in society and in the
professions, this way of doing things has attracted increasing
criticism. Undoubtedly, this forms part of the rationale for applying
trade practice law to the health sector and to advertising by
doctors, and to the interpretation of such law by the Australian
Competition and Consumer Commission. Under federal law in Australia
the Trade Practices Act 1974 (Cwlth) now permits advertising,
unless it is likely to mislead or deceive. Direct advertising
by doctors to the public is now lawful.
The article by Ring in this issue of the Journal (page 597)3
asks if ethical standards are a casualty in the promotion of cosmetic
surgery, and shows that this specialty is being seen as part of
the beauty industry rather than a procedure for meeting health
needs. The promotional strategies used do not sit well within
the medical environment. The beauty industry promotes a body image
that draws on vanity rather than on health. It creates expectations
linked to perpetual youth, which can feed insecurities in people
of both sexes, and contributes to a youth culture which treats
with contempt the results of the ageing process.2
On the other hand, people who wish to change their image are
now being informed that there are treatments available. The World
Medical Association Declaration on the Rights of the Patient says
that, "The patient has the right to self-determination, to
make free decisions regarding himself/herself. The physician will
inform the patient of the consequences of his/her decision".4
Should not patient autonomy include the freedom of adults to purchase
these treatments, as long as the advertising surrounding them
remains within the ethical boundaries of truthfulness?
Where should the boundaries lie between medicine as traditionally
defined, and lifestyle-modification medicine? The Australian Medical
Association (AMA) Code of Ethics encourages doctors to promote
the health and well-being of their patients and prohibits doctors
from behaving in their own self-interest. It also says that doctors
have "a responsibility to their patients to recommend only
those diagnostic procedures necessary to assist in the care of
patients and only that therapy necessary for their well being".5
Many patients would say that changing their image through cosmetic
surgery is for their well-being, as it would improve their quality
of life. It is a personal decision based on personal perceptions.
If we consider that cosmetic surgery is part of medicine, then
the advertising and promotion of such procedures must adhere to
the ethical guidelines of the medical profession. The AMA believes
that, as a general principle, advertisements must be honest, must
not exploit patients' vulnerability or lack of medical knowledge,
and should provide only factual information. Any advertisement
for a doctor's services should present information that is reasonably
necessary for making an informed decision about the appropriateness
and availability of the medical services offered.6
In recognition of the need for a middle ground between the traditional
ban on advertising and the current deregulated environment, the
Medical Practitioners Board of Victoria has produced draft guidelines
which will provide clear guidance for doctors who wish to advertise
their services. A summary of the guidelines is presented in the
Box.7
Summary of the Medical Practitioners Board of Victoria's draft
guidelines for medical advertising7*
Ban the use of "before and after" photography, which
is common in advertisements for cosmetic surgery.
Limit advertising to a factual statement of services offered.
Warn against the creation of "unwarranted or unrealistic"
patient expectations of treatment.
Continue the ban on the use of patient testimonials.
Prohibit advertising which encourages inappropriate use of medical
services and contains information or language which could cause
fear or distress or make people believe their health may suffer
from not using a medical service.
* Reproduced with permission.
Whether we agree with changes in contemporary views which have
allowed doctors to enter the free market of advertised services,
or prefer the traditional culture, the one interwoven thread which
must run unbroken through the fabric of medical practice is that
of standards of ethical practice and the primacy of the patient.
References
Committee of Inquiry into Cosmetic Surgery. The
cosmetic surgery report: report to the NSW Minister for Health
– October 1999. Strawberry Hills [Sydney]: Health Care Complaints
Commission, 1999.
Miller FG, Brody H, Chung KC. Cosmetic surgery and the internal
morality of medicine. Camb Q Healthc Ethics 2000; Summer, 9: 353-364.
Ring AL. Using anti-ageing to market cosmetic surgery: just good
business, or another wrinkle on the face of medical practice?
Med J Aust 2002; 176: 597-599. <eMJA full text> <PubMed>
World Medical Association Declaration on the Rights of the Patient
<www.wma.net/e/policy/17-h_e.html> (accessed 22 May 2002).
Australian Medical Association. Code of ethics, 1996. Canberra:
AMA, 1996.
Australian Medical Association. Position statement: advertising
and endorsement, 1996. Canberra: AMA, 1996.
New medical advertising guidelines. Vic Doc 2002; March: 29.
(Received 7 May 2002, accepted 21 May 2002)
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