For a number of years, the Council for Medical Ethics has been working on issues pertaining to aesthetic medicine. Here, the Council responds to specific questions from the Norwegian College of General Practice.
In two meetings in 2018, the Council for Medical Ethics deliberated on a complaint from the Norwegian College of General Practice (NCGP) regarding a matter of principle. The complaint was related to the practice of ‘aesthetic medicine’, here used as a collective term for surgical and non-surgical treatment in which the primary reason to undertake the intervention is of an aesthetic rather than medical character.
Issues pertaining to aesthetic medicine have previously been addressed by Henrik Vogt and Andreas Pahle in newspaper articles (1, 2) and in the Journal of the Norwegian Medical Association (3).
The Council for Medical Ethics has been engaged with these issues also on previous occasions. We have received regular complaints, especially with regard to marketing. In 2016, we held a seminar with the title The ethics of aesthetics, in which we sought dialogue with practitioners of cosmetic surgery. The Norwegian Society for Aesthetic Plastic Surgery organises the majority of these surgeons and is a sub-group of the Norwegian Association of Plastic Surgeons, the medical specialty organisation. This activity is governed by regulations (4, 5) and internal guidelines (6, 7).
In this work, the Medical Ethics Council has leaned on a report from the Nuffield Council on Bioethics (8). We wish to add that our response was submitted with a minority statement (one member). In the remainder of this article, the questions from the Norwegian College of General Practice will be given as sub-headings, with the Council’s statement in the subsequent paragraph.
Is the performance of aesthetic medicine by doctors considered ‘ethically acceptable practice’?
The Council for Medical Ethics believes it is impossible to give a general response to this question. ‘Aesthetic medicine’ is a wide concept, and no clear and general boundary can be drawn between acceptable and unacceptable practice. There are undoubtedly a number of enterprises that do not run their practice in a way that the Council would deem ethically acceptable, but the question of whether an activity is ethically acceptable must be decided on a case-by-case basis. In the Council’s opinion, key factors would be professional integrity, marketing and information about the service in general and to each individual patient, the assessments made, to whom the service is offered and the context within which the service is provided.
In this context, we would like to refer to the Code of Ethics for Doctors, Chapter I, Sections 2, 3, 7, 8, 9, 10 and 12, and Chapter III on marketing and other information about medical services (9).
May such activities be referred to as ‘medical practice’?
In general, it is an intriguing question whether aesthetic medicine does in fact fall within doctors’ main remit, such as it is described in the Code of Ethics for Doctors, Chapter I, Section 1: A doctor shall protect human health. A doctor shall cure, alleviate and console. A doctor shall help the ill to regain their health and the healthy to preserve theirs.
In all cases, the members of the Norwegian Medical Association are bound by our ethical code.
Are such activities consistent with the regulations on marketing of medical services in the Code of Ethics for Doctors?
An assessment of whether marketing and other information about the service comply with the provisions in Chapter III of the Code of Ethics for Doctors must be undertaken on a case-by-case basis.
The Council for Medical Ethics receives an increasing number of complaints regarding various forms of marketing. The complaints are dealt with according to the Regulations of the Council for Medical Ethics and frequently result in criticism related to violation of the marketing rules. In their statements, many parties have pointed out that violations are brought to the Council’s attention ‘too randomly’ and thus affect the actors unevenly, and that it is challenging to undertake marketing in a private market while remaining compliant with the ethical rules.
There is a growing market in private health services characterised by competition and earnings, which create a need to market these services quite differently from previous methods of marketing health services.
The Council for Medical Ethics believes, however, that it is increasingly important for doctors to market their services in a restrained manner and in accordance with the Code of Ethics for Doctors. This is essential to preserve the legitimacy of and trust in the medical profession, as well as from the perspective of prioritisation and economics. The main idea behind the strict rules is to clearly signal that doctors should not help fuel unnecessary health anxiety and unrealistic expectations of the benefits that medical services may provide.
In this context we would like to refer to Chapter III, Section 1, of the Code of Ethics for Doctors (bold type added by the Council):
Marketing and other information concerning medical services may only contain information about:
the location, opening hours, and administration of the practice,
the type of practice, specialty (see § 2 below) and title (see § 3 below) of the practitioner,
diagnostic and therapeutic methods
the fees charged.
The information must reflect generally medically accepted and/or scientifically documented diagnosis of indications and/or methods. The information must contain nothing incorrect or misleading to the public. Marketing that may cause anxiety, prejudices or unrealistic expectations must not occur.
Marketing and other information must not mention possible or expected results of specific services, or the quality of the services. No formulations may be used which could give the public the impression that by failing to avail oneself of the services advertised, one is placing one’s own or other persons’ somatic, mental or social health at risk.
Marketing and information about the medical practice must be in accordance with the intentions indicated in the above.
Greater transparency and more information regarding the Council’s practices in this area have been called for, and in 2017 we took the initiative to amend the Regulations of the Council for Medical Ethics . The proposals were adopted by the Annual Representative Meeting in 2018. In this context we would like to note in particular that as a rule, violations of Chapter III on marketing henceforth will not be exempt from public disclosure, with the exception of personal and confidential information.
Aesthetic medicine as ‘extra services’ in the public healthcare system
The Council was also requested to assess ethical issues arising when public service providers offer aesthetic medicine as an additional service. This is challenging for the practitioners. The Council presumes that the doctors have clarified with their employers (local councils, health enterprises, regional health authorities) that they have permission to provide such services (cf. Section 19 of the Health Personnel Act). The key issue is to organise the activities in a way that makes it clear to the patients what is part of the public system and what is not. If any confusion occurs, a general assessment is made on the basis of a number of factors, such as the name of the activity, location, opening hours, information boards and whether there are separate support services/auxiliary personnel.
Is it reasonable for the Norwegian Medical Association to endorse this activity? For example, will the Norwegian Medical Association provide legal assistance if these doctors cause harm to people in the course of their work?
The conditions for membership are laid down in the by-laws of the Norwegian Medical Association, which also determine the rights of the association’s members. The fact that a doctor is a member of the Norwegian Medical Association does not necessarily mean that the association endorses/approves of the activities of this member.