Medical Ethics and advertising: On the Influence of advertising Professional Ethics
Gonzalo Herranz, department Bioethics, University of Navarra
Presentation at the 12th congress of Plastic Surgery
Santo Domingo, October 11–16, 1998
An Ethical Analysis of advertising
The Implications for Plastic Surgery
It is widely believed among physicians that advertising ethics advertising a peripheral and largely irrelevant aspect of professional ethics. Both within and outside the profession—but especially among bioethicists—there is a tendency to view advertising not as part of the core of medical ethics, but rather as a set of formalistic, almost ceremonial rules belonging to an obsolete label .
That is not my view. I believe that advertising a significant—and by no means secondary—role in the issue of medical ethics. I will try to demonstrate this this morning. The reasons supporting this assertion are easy to state: advertising only helps shape society’s image of doctors and define how we are perceived from the outside; it also determines how we doctors see ourselves.
Because the image people form of medicine and doctors is shaped, in part, by what advertising reveals to them. advertising—that is its function—brings medicine into the public eye. It provides people data they data judge us, data tells them what doctors are like and how we act.
The nature of advertising determines whether medicine—and, with it, the medical specialties—is viewed as a genuine profession that values truthfulness, sincerity, the ideal of service, and an acknowledgment of its limits; or, conversely, that medicine and its specialties appear overly concerned with financial gain and the promotion of healthcare consumerism, barely distinguishable from any other business (Leavey, 1989).
Dyer (1985, 1988, 1995) has put forward the thesis the Degree commercialization of medicine is advertising the nature of advertising . Until recently, the codes of ethics of many European countries included an article stated, with slight variations: “Medicine is a noble and exalted profession that under no circumstances may be practiced as a business.” This brief and pithy article disappeared in the most recent revisions of most of these codes: in Spain, it was removed in 1990. It is a pity, for that article reminded article of the vocational and generous essence of the medical calling. This is something we should always keep in mind, especially when, as we will see in a moment, certain laws and judicial rulings at the highest level have already defined medicine as an activity that must be governed by business principles and standards.
The fact that medicine is a profession and not a business is particularly important to those of us gathered here this morning: there are very few fields of medicine that are as vulnerable to such a radical shift as plastic surgery, especially in its cosmetic aspect.
In this presentation, I will therefore attempt to provide data support of the thesis the ethos of the medical profession depends on how advertising is conceived and practiced. If my argument is convincing, we will be able to reach a conclusion: that scientific associations—and, specifically, those that make up this Ibero-Latin American Federation of Plastic Surgery—will have to assume a permanent, active, and effective leading role in the regulation and control of advertising in the future.
An Ethical Analysis of advertising 
advertising to influence, to elicit certain responses from the public: first and foremost, to inform and educate them; often also to create in its audience the impression that what is being advertised is desirable, or even necessary; and also to persuade them that what is being advertised is somehow different and better.
There are, therefore, several types of advertising and educational on the one hand, and persuasive and distinctive on the other—that exhibit widely varying ethical tones
advertising does not pose any substantive ethical problems, provided it is conducted within reasonable limits. Information provides people with data need to make rational, that is, informed, decisions. The data a physician’s advertising provides to the public through various media (newspaper ads, letterhead and prescription forms, door signs, professional directories, and yearbooks) must be presented truthfully and discreetly. In accordance with professional ethics, this information shall be limited to the physician’s name, office address, issue , schedule , the schedule center or group they work, their specialization program , officially recognized and legitimately held credentials, and other data by local customs or national regulations.
The second type of advertising—educational advertising—is a beneficial byproduct of the knowledge dissemination—whether oral, audiovisual, or written—through commentaries or articles on health topics; of sponsorship Education activities; and of participation in such activities. To truly deserve the label “educational,” the knowledge dissemination be free of any promotional bias or any encouragement of medical consumerism.
advertising carries serious ethical risks. Through its claims, it captures the attention of potential customers and promises them more than it can deliver (Hyman, 1990). It flatters patients’ unconscious desires and manipulates their fantasies and whims, for there will always be people who succumb to the impossible promises of beauty, slenderness, youth, erotic appeal, or physical strength presented to them by this subject advertising. Incitemental language aims to create a sense of urgency, persuades people not to miss the opportunity, or lulls them with false hopes. Above all, advertising relies on the persuasive rhetoric of the image. I recall a Catalog cosmetic procedures, distributed in Spain years ago through a widely circulated newspaper, in which the manipulation of the vulnerability of those with physical imperfections reached the level of a fine art.
Finally, advertising . It is based on explicit references to the distinct and differentiating qualities of the product, the price, the personality, or the superior skills of the service provider, as well as their possession of exclusive abilities, competencies, or technologies that set them apart from others. This subject advertising has never been accepted advertising the medical field (Geist, 1978). There persists among professionals a sort of almost instinctive aversion to declaring oneself superior to others. Although, it must be acknowledged, there is no shortage of colleagues who do not object to being the subject of that variant of advertising known as advertising (Rodning and Dacso, 1987).
However, in this era of the new medical-industrial complex (Relman, 1980), hospitals and health insurance companies have no qualms about using the most aggressive marketing techniques to compete with their rivals and dominate the market. Although Engelhardt and Rie (1988) quite boldly, and more moderately Agich (1990), have outlined a theory—more neocapitalist than liberal—of medicine as a business, it must be acknowledged that a critical ethics of healthcare organizations remains to be developed—specifically, an ethics for the economists and planners who lead medical services and technology companies, one that incorporates the strong values of classical medical ethics. For now, ethics require healthcare institutions to engage in advertising of unsubstantiated, false, or misleading claims, or claims that omit necessary information (American Medical Association 1996, American College of Physicians, 1998).
In Europe, the professional tradition prohibiting advertising has recently received support from EU authorities. A directive from the European Parliament and committee , which regulates advertising , supports “the maintenance or establishment of prohibitions or restrictions on the use of comparisons in advertising professional services, including those imposed by a competent body responsible for regulating a professional activity.”
However, not all lawmakers share this view regarding advertising . The legal system has made a forceful entry into our field. First, even violently, in the United States, and later more gently in the United Kingdom, judges have ruled that advertising must be freed from the control of medical corporations and enter the realm of free skill of advertising . In 1982, the U.S. Supreme Court upheld a decision by the Federal Trade Commission that struck down professional restrictions on advertising. It condemned them because, in its view, they were based on corporate interests, perpetuated status , made medical care more expensive, and limited patients’ freedom to seek and purchase what best suited them. In fact, the ruling concluded that medicine can provide the public with more beneficial services if it is subject to the rules governing business rather than those regulating the professions. And so, almost overnight, medicine became commercialized (Reade and Ratzan, 1987).
A somewhat parallel story unfolded in the United Kingdom in the 1980s. A decision by committee and Mergers committee relaxed the highly restrictive regulations that had prevailed there until then. Doctors viewed the assessment of that decision as amounting to an undesirable commercialization of medicine (Irvine, 1991; Gillon, 1989).
In contrast to what has happened in the area , in many other countries the law continues to impose restrictions on advertising . In Spain, this is done by Law 14/1986, the General Health Law, and Royal Decree 2827/1977, which established the Review Committees for advertising . Law 34/1988, the General advertising Law, also assigns a special status to this advertising . The Medical Association has recently published detailed rules and regulations advertising 1996).
How long will this status last? It seems that the tide is turning in favor of removing barriers to free skill. The legal revolution, which began in the United States by shifting the legal boundaries of advertising , has brought about significant changes in the professional ethos. Today, we can no longer speak only of doctors and patients, but also of providers and clients; not only of healthcare, but of healthcare consumerism; not only of doctors administering medical services, but also of companies in the medical-industrial complex selling catalog items of services chosen by the buyer. Much information and a significant number of offers and requests are now processed via the internet. National borders are disappearing, swept away by new modes of communication. The medical act is commodified (Sabatini, 1987), and the traditional pact of trust and loyalty between doctor and patient is subsumed into a contract that the client enters into with companies competing for hegemony in the healthcare market. A new atmosphere is thus created: the doctor-patient relationship tends to be framed in economic rather than ethical terms, and in electronic rather than empathetic terms (Mandel, 1998).
This phenomenon is not limited to healthcare organizations, multinational integrated healthcare service providers, or healthcare conglomerates formed through alliances between the medical and pharmaceutical industries. The commercial mindset is contagious and permeates the entire field of medicine: many doctors, everywhere—not just in the English-speaking world—want a share of the profits generated by the new landscape of corporate medicine.
The Implications for Plastic Surgery
“The abuse of advertising freedom advertising the traditional doctor-patient relationship and lead to a loss of trust in the medical profession on the part of patients.” So states a document from the British Medical Association (1991). Is this an exaggeration, or is it a prediction that is already beginning to come true?
Probably, the area medicine where this dilemma is most pressing is plastic surgery. Therefore, in my view, this specialization program destined to play an inspiring role in the future of advertising . This is because the public—and especially judges—are very aware of the unique status cosmetic surgery within the broader field of medicine. A series of inconsistent, back-and-forth rulings has recently emerged in Spain regarding the nature of cosmetic surgery procedures. For some judges, this is a standard medical procedure that, while requiring diligent application of resources and an added measure of responsibility, entails nothing more than an ordinary obligation to provide services. For others, these subject which, in principle, do not have a curative purpose—are interventions in which the obligation to achieve a result takes precedence. This view shifts cosmetic procedures into the area transactions and commercial contracts (Asensi, 1998).
A subject advertising would provide firm and public support for the notion that cosmetic surgery is breaking away from the common ethical framework of medicine to become a field governed by business norms, where the rule of “caveat emptor” applies! That would be an ethically impoverishing development (Havard, 1989). One of the clauses in the recent regulations issued by the British discipline body is therefore particularly apt: “The information you publish must not contain claims about the quality of your services nor include comparisons with services provided by other colleagues. You must not, under any circumstances, offer guarantees of cure, nor may you exploit patients’ vulnerability or their lack of medical knowledge” (General Medical Council, 1997).
An analysis of the advertising in the media, on the internet, and on TV shows—either individually by some plastic surgeons or collectively by certain aesthetic medicine associations—reveals troubling trends. In women’s magazines or general-interest publications, advertisements appear promising beauty, slenderness, and elegance, guaranteeing results, with details on the time and cost of each procedure, and, of course, the surgeon’s phone number and address. The primary purpose of this advertising is advertising to provide data would help patients and potential clients with the necessary—and difficult—task of making informed decisions. Rather, it aims to create demand, downplay risks, guarantee results, and raise expectations, going so far as to turn desires into primary needs or inalienable rights.
From the standpoint of professional ethics, only advertising informative advertising is acceptable. It is the only form of advertising whose content is objective, verifiable, and free from exaggeration. advertising is not immune to the risk of inducing in some people a desire for unnecessary services and of creating a state of anxiety or dissatisfaction with their own bodies.
A good way to determine what needs to be done in the future is to identify our shortcomings. If one reviews the professional standards on advertising in the medical codes of ethics of Ibero-Latin American countries (I have been able to study those of 17 countries: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Ecuador, El Salvador, Spain, Guatemala, Honduras, Paraguay, Peru, Portugal, Uruguay, and Venezuela), a status deficiency becomes apparent. Many need to be updated, as they have remained frozen in the past. The long, detailed, and now octogenarian list of prohibitions from the Code of Medical Ethics, the Razetti Code of 1918, persists almost verbatim in many codes (Argentina, Bolivia, Costa Rica, Ecuador, Guatemala, Honduras, Paraguay, and Venezuela), despite the fact that advertising changed significantly since then. Few address the issue we have discussed here today: the Code of Medical Ethics of high school Peruvian high school , from 1970, states that since medicine is not a commodity, it must be practiced with moderation, honesty, and discretion. And the Code of Medical Ethics of the Uruguayan Medical Union, dated 1995, classifies, in article , any advertising , manipulative, or unfair advertising aimed at attracting clients as a serious ethical violation.
But the codes of ethics of national medical associations in Latin America are very conservative. They are not instruments that readily embrace change.
Perhaps there is no other option but to call upon the vitality of the Ibero-Latin American Federation of Plastic Surgery to undertake the drafting and approve model code of ethics model will inspire the work of its members. A humane and intelligent code that, by placing respect for people in a preeminent position and by reminding everyone that there is no substitute for the skill humanity of the physician—which is the physician’s ethical heritage—and that, in the necessary chapter on the ethics of advertising, makes clear that advertising must always conform to the classic principle of “do no harm.”
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