Ethical behaviour is integral to medical practice. Society rightfully trusts surgeons to have ethical standards above those of the wider community. By and large the profession has repaid that societal trust by upholding such standards. However, the growing influence of social media on marketing and self-promotion, and the inappropriate prioritisation of entrepreneurial business practices, means we are now experiencing a shift away from patient-centered decision-making to outcomes that favour surgeons.

Conflicts of interest have always existed within our practice but the most common and identifiable that often underpin dubious ethical behaviours relate to money. At best, unethical behavior can be inadvertent, where a surgeon lacks reflective practice. At worst, it is driven by greed and ego where the patient becomes a commodity to be exploited.

Plastic surgery is a profession characterised by responsibilities. While we all expect to make a living from our skills, it is ethically wrong to prioritise profits or convenience over patient outcomes. Patient interactions should be about the patient, not a business model. Every patient deserves our genuine respect—they trust us to do for them what we would want done for our own families.

So why are we talking about this and why is it important now?

Medical practice advertising and promotion has generally created ethical dilemmas. Once considered unseemly, unprofessional and unethical, the concept of marketing has more recently been accepted as tolerable, or a necessary evil, then normal and now, by some, as important. But patients are not just buying products. They are making a conscious choice and relying on the professional integrity of surgeons. Advertising in medicine should be directed at educating patients and providing factually accurate information to ensure informed consent, not at presenting exaggerated or baseless claims of expertise or coercing patients into undergoing unnecessary or inappropriate procedures.

The consequences of unethical behaviour are greater for surgeons than other professions. There is the real chance of patients being harmed, be it financially, psychologically or physically. The profession is held in high regard by the community and so breaches of ethical standards are keenly felt. The community has an unwritten agreement with surgeons that the standards and integrity we uphold are paramount. They trust us in a way they would not trust others. Patients rightfully expect that the care we give them is, unquestionably, in their best interests.

In an era where advertising, self-promotion and ubiquitous social media can blur the lines of professional standards and decency, surgeons need to maintain their moral integrity. That integrity is a non-negotiable characteristic of our profession. The ethical framework by which we exist as surgeons must be solidly based in our professionalism. Our moral cues don’t come from Instagram, where clients may have a different sense of the seriousness and consequence of surgical procedures. In this environment, surgeons must refrain from social media commentary, regardless of prospective patients’ desiring casual and ‘cool’ interaction.

In Australia and elsewhere, there has been a paucity of guidelines and advice for surgeons to follow regarding ethical standards in relation to appropriate social media. In the USA, this has resulted in a concerning escalation of unacceptable unethical behaviours by some surgeons on social media^1,2 resulting in a distinct sense that ‘the genie is out of the bottle’ and can’t be put back.

This worrying erosion of ethical standards prompted the Australian Society of Plastic Surgeons (ASPS) to respond to the issue of inappropriate use of social media within the broader context of developing a stronger ethical framework for member surgeons. The society will be including specific guidelines for social media in its revised Code of Conduct and plans to monitor the content of members’ websites. ASPS is hopeful that creating greater awareness of unacceptable behaviour will ensure members act ethically, review and modify any unacceptable content and continue to be vigilant in this area in the future. If awareness alone is insufficient motivation then the ASPS will assist surgeons to understand their moral responsibilities.

Under the new guidelines ASPS members are personally responsible for their social media content regardless of whether this may be outsourced to others within, or in association with, their practice—even if the content was originally generated and posted by patients and already in the public domain. There are many examples of photographs or videos re-posted by surgeons that are demeaning, objectifying or present sexualised imagery. The re-posting of such images is unacceptable. Nor should surgical procedures be trivialised. As the community is saturated with digital, electronic and print media stories about cosmetic procedures, there is an even greater responsibility for surgeons to reinforce the notion of serious decision-making about procedures.

Likewise, ASPS does not support the posting or streaming of live operative videos on any platform. Posting live intraoperative videos is of no benefit to patients and involves increased risks for patients and surgeons, including: interference with concentration and decision-making during surgery; prolonged operations; inappropriate patient consent given the unpredictable nature of surgical procedures; family distress in the event of an unexpected surgical occurrence; revelations of the identity of patients or other people in the operative environment; breach of regulations or by-laws of the hospital; and compromised sterility. The educational benefit of an appropriately edited, consensual video of a surgical procedure is clearly superior to a live posting.

Finally, we all share the obligation to use Medicare item numbers ethically. The Australian Government legislates appropriate access to government support for surgical procedures and we are legally bound to follow the correct definitions. Using item numbers incorrectly, no matter how well-intentioned, cannot be considered as beneficence as it wrongly consumes public funding.

Plastic surgery is a specialty requiring intellect, hard work and dedication. The profession should be measured by our integrity, honesty and commitment to treating patients with respect and not as commodities to be exploited. Unless we understand and embrace the concept of honest reflective practice, we risk inadvertently allowing transgressions and damaging unethical behaviors to become ingrained. Patients can only have faith in us if we always do the right thing, even when no one will find out.

Surgical practice can make us invisible to others but never to ourselves. Certainty in our own personal integrity is a prerequisite for the trust of others. If we pursue a genuine intention of contributing to the welfare of the community then we must make sure we never give people any reason to question our ethics. Our integrity is not all we have as surgeons, but without it we don’t have much.³