The Divergence of Ethics and Professionalism in the Social Media Arena

Advertising and publicity have always played a uniquely prominent role in plastic surgery but never before with such immediacy and ease for mass accessibility. Social media have given us the opportunity to shape not only our patients but ourselves by creating a public image of us as individual providers and as a profession. Increasingly, plastic surgeons are enticed to skirt the limits of professionalism as we engage in social media's many forms of communication, entertainment, and marketing. Today, we face a new struggle to preserve our professional image and control the form it takes. Ethics and professionalism are not the same, even if they are closely connected. For example, a surgeon who posts patient images without consent is unethical. However, the surgeon who posts lewd patient images with consent is unprofessional. It is often unclear where ethics ends and professionalism begins and the two are therefore often conflated. Three basic principles derived from the Belmont Report published in 1979 are generally considered to dictate ethical prescriptions.1 They are as follows: respect of persons, beneficence, and justice. The principle of respect for persons incorporates at least two ethical convictions: first, that individuals should be treated as autonomous agents, and second, that persons with diminished autonomy are entitled to protection. Beneficence demands that persons are treated in an ethical manner not only by respecting their decisions and protecting them from harm, but also by making efforts to secure their well-being. Justice refers to “fairness in distribution” or “what is deserved.” An injustice occurs when some benefit to which a person is entitled is denied without good reason or when some burden is imposed unduly. These principles form the foundation for the field of bioethics, and were used to help formulate the Code of Ethics for the American Society of Plastic Surgeons. The commonality among professions is that they have a commitment to society by providing services requiring mastery of complex knowledge and/or skills. Specifically, the medical profession is unique in that patients (society) must trust that physicians are acting on their behalves. This concept is further amplified when considering a surgical patient who consents to have his or her surgeon perform an invasive procedure for improvement in quality of life but risks an untoward complication(s). The effects of surgery cannot easily be undone and therefore the importance of the surgeon’s professionalism is paramount. Many would agree that professionalism is easy to recognize but difficult to explicitly characterize, “I know it when I see it.” Simply stated, professionalism encompasses the goals, behaviors, and attributes that characterize a profession.2 It can be defined not only by the members of the profession, but also by the public who bring to the table their expectations of professional standards. To better understand the distinction between ethics and professionalism, we may attempt to gain insight from one of our professional counterparts, the legal profession. Former Georgia Chief Justice Harold Clarke described the distinction between ethics and professionalism, as “the idea that ethics is a minimum standard which is required of all lawyers while professionalism is a higher standard expected of all lawyers.” Ethics is regarded as adhering to the rule of law, whereas professionalism calls for a commitment to improvement of the law.3 Although certain ethical principles remain steadfast, and universally applicable to all physicians, establishing modern and clear definitions of professionalism requires more variability depending on the practice and the culture surrounding it. Falsifying information, willful negligence, improper relationships with patients, and practicing in substandard or unsafe conditions, for example, are clearly ethical violations. In contrast, violations of professionalism are too often subject to opinion and generational bias. Today’s standards of professionalism are evolving in a climate characterized by the ever-increasing prevalence of social media, impact of patient expectations and opinions on success, competition with peers and other encroaching specialties, entrepreneurism, changing social mores, and shifting baselines regarding advertising. This is further complicated by the rise of patient self-exploitation in images, videos, and medical stories being broadcast globally across social media. Although questionable marketing practices are frequently brought to the attention of the American Society of Plastic Surgeons ethics committee, the lack of historical perspective by which to judge them is problematic. Advertising has expanded exponentially over the past 15 years. It is now almost expected that we (plastic surgeons) avail ourselves of Web sites, Snapchat, Instagram, Twitter, and slick marketing tactics to promote our practices. Media networks are created using consenting patients as co-stars. Groupons, specials, and promotions flood the social media channels and are used as much to meet prospective patients’ expectations as to remain competitive in today’s market. Although these types of practices may be distasteful to some, they represent widespread emerging trends. Broadening social mores mean that it is much harder to define a lapse in professionalism today by saying “I know it when I see it.” Ultimately, it appears most useful to treat ethics and professionalism as two distinct but overlapping domains. “Medical professionalism is rightly understood as relevant to medical ethics only because professionalism concerns those virtues or attributes that foster health practitioners’ abilities to recognize, interrogate, and to enact the ethical duties they possess in their roles.”4 In 2016, the American Society of Plastic Surgeons Code of Ethics was broadened to incorporate standards of professionalism and decorum in all public and private electronic communications with or concerning patients or colleagues. Surgeons must obtain specific informed consent for a patient’s video to be broadcast live on SnapChat for 24 hours. Although this level of informed consent meets the Code of Ethics, it does not fully address the sophisticated nuances of social media platforms. Should our standards of professionalism include accountability for how this may impact the patient in the future? Demonstrating professionalism entails that we inform patients that they are giving consent to having their images posted on a platform that is permanent and searchable, and that neither the patient nor the surgeon will maintain ownership of those images. What then remains regarding the commonality of ethics and professionalism? Despite all the dynamism of the current climate in which we practice, standards of ethics and professionalism will always converge over patient safety and patient protection (beneficence). Plastic surgery is a field characterized by innovation. Responding to market forces, using new technologies, and finding novel ways to promote one’s practice are to be expected. Distancing the general public’s actions from those expected of a professional and placing the needs of the patient above all else, however, is to be mandated. Our Society can provide guidelines with an understanding of the market forces and ever-changing arena and market forces that are at play. Ultimately, a profession is not just one person, and we must consider how our individual actions reflect on our specialty. For plastic surgeons, our frequently subjective clinical objectives require that our standards of professionalism go above and beyond what meets the minimum requirements of our Code of Ethics.