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The Ethics of Sharing Plastic Surgery Videos on Social Media: Systematic Literature Review, Ethical Analysis, and Proposed Guidelines

Dorfman, Robert G. M.Sc.; Vaca, Elbert E. M.D.; Fine, Neil A. M.D.; Schierle, Clark F. M.D., Ph.D.

Plastic & Reconstructive Surgery: October 2017 - Volume 140 - Issue 4 - p 825–836
doi: 10.1097/PRS.0000000000003695
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Summary: Recent videos shared by plastic surgeons on social media applications such as Snapchat, Instagram, and YouTube, among others, have blurred the line between entertainment and patient care. This has left many in the plastic surgery community calling for the development of more structured oversight and guidance regarding video sharing on social media. To date, no official guidelines exist for plastic surgeons to follow. Little is known about the ethical implications of social media use by plastic surgeons, especially with regard to video sharing. A systematic review of the literature on social media use in plastic surgery was performed on October 31, 2016, with an emphasis on ethics and professionalism. An ethical analysis was conducted using the four principles of medical ethics. The initial search yielded 87 articles. Thirty-four articles were included for analyses that were found to be relevant to the use of social media in plastic surgery. No peer-reviewed articles were found that mentioned Snapchat or addressed the ethical implications of sharing live videos of plastic surgery on social media. Using the four principles of medical ethics, it was determined that significant ethical concerns exist with broadcasting these videos. This analysis fills an important gap in the plastic surgery literature by addressing the ethical issues concerning live surgery broadcasts on social media. Plastic surgeons may use the guidelines proposed here to avoid potential pitfalls.

Chicago, Ill.

From the Division of Plastic Surgery, Northwestern Memorial Hospital.

Received for publication November 16, 2016; accepted March 22, 2017.

Disclosure: None of the authors has a financial interest in any of the products or devices mentioned in this article.

Supplemental digital content is available for this article. A direct URL citation appears in the text; simply type the URL address into any Web browser to access this content. A clickable link to the material is provided in the HTML text of this article on the Journal’s website (www.PRSJournal.com).

A “Hot Topic Video” by Editor-in-Chief Rod J. Rohrich, M.D., accompanies this article. Go to PRSJournal.com and click on “Plastic Surgery Hot Topics” in the “Digital Media” tab to watch. On the iPad, tap on the Hot Topics icon.

Clark F. Schierle, M.D., Ph.D., Northwestern Specialists in Plastic Surgery, S.C., 676 North Saint Clair Street, Suite 1575, Chicago, Ill. 60611, drschierle@northwesternplastics.com

Social media represent a novel platform by which plastic surgeons can both educate and market to patients. As of 2016, Snapchat was the most popular social media site among teenagers and young adults in the United States, and Instagram now has more than 400 million monthly active users.1 Surgeons have also uploaded numerous videos on YouTube made for both marketing and educational purposes. Nevertheless, the rising popularity of Snapchat and Instagram, as opposed to more “traditional” social media platforms such as YouTube, Facebook, and Twitter, has not gone unnoticed. Some plastic surgeons have gained large followings on Snapchat and Instagram by broadcasting live surgery videos including theatrics such as dressing in costumes, dancing, and flaunting removed tissue such as abdominoplasty specimens. Many plastic surgeons question the ethics of broadcasts done more for the purposes of entertainment than for education, and have called for the development of more structured oversight and guidance in this area.2–5

To date, no official American Society of Plastic Surgeons guidelines exist regarding video sharing on social media platforms. Little is known about the ethical implications of social media use by plastic surgeons, especially with regard to video sharing. To this end, we aim to provide a comprehensive review of what is known about social media use in plastic surgery. Furthermore, we conducted an ethics analysis of video sharing social media use in plastic surgery, and propose guidelines for the judicious use of these media outlets to uphold the highest level of professionalism within our specialty.

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METHODS

A MEDLINE search was conducted on October 31, 2016, using the following terms, combined as appropriate: “plastic surgery,” “aesthetic surgery,” “social media,” “Instagram,” “Snapchat,” “ethics,” and “professionalism.” The search was limited to publications in the English language from January 1, 2000, through October 31, 2016. January 1, 2000, was selected as the lower limit of article publication date, as this corresponds with the approximate peak of the “dot-com bubble” and precedes the founding of social media platforms such as YouTube, MySpace, Facebook, Twitter, Vine, WhatsApp, RealSelf, Instagram, and Snapchat. Extracted variables included article title, date and journal of publication, type of study, and a summary of results. The literature search was performed by two authors (R.G.D. and E.E.V.), and disagreements were resolved by consensus. Eligible articles included cross-sectional studies, surveys, quantitative and qualitative analyses, case reports, guidelines, tutorials, opinion pieces, and reviews of the literature pertaining to social/electronic media use in plastic surgery, with a focus on the ethics and professionalism of its use. Such broad inclusion criteria were permitted given the paucity of articles pertaining to video sharing platforms. This broad review served to lay the groundwork for what has been published thus far regarding the ethical concerns raised by social media use, and as a segue for the discussion and call for new formalized guidelines to assist plastic surgeons in upholding the highest standards of professionalism with the advent of newer video sharing platforms.

The four principles of medical ethics were used for discussing the ethics of video sharing platform use in plastic surgery and for the development of our proposed guidelines.6 (See Figure, Supplemental Digital Content 1, which shows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist for systematic literature review, http://links.lww.com/PRS/C384.)

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RESULTS

Systematic Review

The initial Medline search yielded 87 articles and abstracts (Fig. 1). Thirty-eight articles were excluded after title and abstract review, as they were not related to social media use in plastic surgery. Full-text review of these remaining 49 articles led to exclusion of 15 additional irrelevant articles, resulting in 34 final publications for analysis. Thirty-two of these included articles were published in plastic surgery journals. Opinion pieces were the most common type of article identified (n = 13), with tutorials being the second most common format (n = 5). In addition, surveys (n = 4), quantitative and/or qualitative analyses (n = 3), reviews (n = 3), cross-sectional studies (n = 2), a guideline (n = 1), and abstracts (n = 1) were identified.

The most common journal for publication on social media use in plastic surgery was the Aesthetic Surgery Journal (n = 11), followed by Plastic and Reconstructive Surgery (n = 10). Other journals in which articles discussing social media use in plastic surgery were found include PRS Global Open (n = 2, including one abstract), Aesthetic Plastic Surgery (n = 2); Journal of Plastic, Reconstructive & Aesthetic Surgery (n = 2), Facial Plastic Surgery Clinics of North America (n = 2), Facial Plastic Surgery (n = 1), The Breast (n = 1), and Journal of Hand Surgery (n = 1).

There were two additional articles deemed relevant to social media use in plastic surgery that were not published in plastic surgery journals. These articles were featured in Journal of Continuing Education in the Health Professions and Health Communication, and consisted of a case report and content analysis, respectively.

Only one article, a letter to the editor, specifically discussed the use of Snapchat in plastic surgery.7 This author recognized the need for updated guidelines for live surgery video sharing on social media platforms, but no such guidelines have been published to date. Summaries of relevant articles are listed in Table 1.7–40

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Ethics of Video Sharing in Plastic Surgery

The four principles of medical ethics include the following: (1) respect for autonomy of the patient; (2) beneficence, or promoting what is best for the patient; (3) nonmaleficence, also known as “do no harm”; and (4) justice.6 Related principles include disclosure and informed consent.

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Autonomy and Informed Consent

Three generally accepted conditions must be met to consider informed consent valid: (1) the patient has been given adequate information regarding the procedure—or in this case, the posting of surgical videos on social media—and its potential risks and benefits; (2) the patient possesses the competence to understand this information; and (3) consent is obtained free of coercion or influence.41

Assuming a competent adult patient, it is the plastic surgeon’s responsibility to educate the patient and thus assist him or her in making an informed decision. However, is it realistically possible for the clinician to remain up-to-date regarding each social media platform’s ever-evolving terms of use policy? If not, how can the clinician be expected to educate the patient on all the potential risks of how posted media may be used? Palacios-González argues that the physician lacks the prerequisite information to properly educate the patient.42 A strategy to satisfy the education element of informed consent is for the clinician to notify the patient that social media terms of use policies evolve, with potential consequences that cannot be foreseen. It should also be emphasized that if the patient requests subsequent removal of posted media, the surgeon has no means to guarantee complete removal, as images and video may have been copied.

Modern medicine champions the idea that surgeons and patients are partners in the decision-making process; however, the relationship remains somewhat hierarchical. The patient may feel coerced—even if subconsciously—to participate in being filmed to be a “good patient.” It is critical for the plastic surgeon to emphasize to patients that their quality of care will not be affected should they decide for or against being filmed or photographed for social media purposes. Conversely, patients may themselves request to have their video shared—particularly among patients who sought out the plastic surgeon based on his or her social media presence—as a means to experience their own brief moment of “fame.”

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Beneficence and Nonmaleficence

Who benefits from video sharing? What are the potential harms? Increased media exposure benefits surgeons by connecting them with prospective clientele. Patients may agree to have their video shared on social media to help future patients learn about the procedure being filmed. The willing patient may also want to feel like a “star,” knowing that he or she is the center of attention in the video.

Although entertainment itself is not unethical per se and has its role if done tactfully, there are concerns of trivializing situations where patients are under anesthesia and are at risk of serious harm. The surgeon risks little potential self-harm unless there is a breach in patient confidentiality or videos are posted without consent, which can result in litigation. Meanwhile, patients risk their images being copied, manipulated, and redistributed, in addition to possible revelation of their identity. Thus, the patient carries the unequal risk burden.

The General Medical Council defines three types of use of patient visual and audio recordings.43 Primary use entails recordings directly used for patient care, such as preoperative photographs for surgical planning. Secondary use includes education and research aimed for other medical professionals such as textbook and journal publications. Tertiary use includes widely accessible public media such as social media and Web site posts.

Increasingly greater opportunities for patient harm exist as one progresses from primary to tertiary uses—among tertiary uses, this risk further increases with minimally edited live posts. Another key difference lies in the educational value and difficultly with content oversight by the social media platform itself and professional surgical societies. Unlike YouTube—and Instagram to a lesser extent—where videos are screened and censored for graphic content or copyright infringement, it is much more difficult to enforce such oversight on Snapchat because posts are live for 24 hours or less.

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Justice

This principle generally concerns the fairness of distributing limited medical resources. However, with regard to sharing content on social media, this principle pertains to how to balance the potentially competing interests of the surgeon and patient. It is in the patient’s best interest to achieve the best possible outcome and to have his or her body, removed body parts, and privacy respected. The surgeon also desires to provide the patient with the best possible result; however, sharing content on social media may be at odds with the patient’s interests.

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DISCUSSION

Social Media Use in Plastic Surgery

The Internet and social media have become omnipresent in the world of plastic surgery. In a 2013 study by Vardanian et al., more than half of surveyed plastic surgeon members of American Society of Plastic Surgeons used social media for personal or professional purposes.36 Patients are increasingly querying the Internet for health-related information and are seeking advice on plastic surgery procedures from social media platforms. A recent study by Montemurro et al. found that 95 percent of patients seeking aesthetic plastic surgery used the Internet to seek health-related information before their consultation.7 Even the American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery now have Facebook, Twitter, and YouTube pages.

However, increasing social media use by plastic surgeons has also led to apprehensions.2–5 Almost one-third of respondents in the 2013 study by Vardanian et al. were concerned about compromising patient confidentiality and violating Health Insurance Portability and Accountability Act regulations on social media. Moreover, one-quarter of these same respondents felt that the American Society of Plastic Surgeons or other similar governing bodies should monitor plastic surgeons’ use of social media to maintain ethical and professional standards.36 This echoes a much broader sentiment within the medical community, as the New England Journal of Medicine, Cancer, and other prominent journals have all highlighted issues with physician use of social media.44–47 New tools often elicit a backlash (i.e., Web sites and before-and-after photograph online postings in the recent past were also controversial48), and one article in the Journal of the American Medical Association reported that as many as 92 percent of executive directors of medical and osteopathic boards in the United States have received at least one complaint about online professionalism violations by physicians.49 The study found that most incidents were reported by patients or their families, although reporting by other physicians was common as well. The most common violations included inappropriate patient communication online, use of the Internet for inappropriate practice, and misrepresentation of credentials. This has led organizations such as the American Medical Association and the Massachusetts Medical Society to develop specific recommendations for social media use by their member physicians.50,51

Despite this, the impact of social media on the practice of plastic surgery remains largely unexamined, and the few publications that do exist focus on sites such as Facebook, YouTube, and Twitter, thereby ignoring newer and trendier platforms such as Snapchat.7–31,33–40 This is especially surprising given that these new platforms have been at the epicenter of much controversy with regard to broadcasting live operations to the general public and questionably inappropriate behavior in the operating room. To date, there have been no peer-reviewed articles in the plastic surgery literature discussing the ethical implications of such broadcasts. Although advertising guidelines by organizations such as the American Society of Plastic Surgeons exist, these guidelines were created before the advent of social media video sharing platforms for use by plastic surgeons to broadcast live operations.52 As suggested in a recent Letter to the Editor by Reissis et al. in Aesthetic Surgery Journal, a review of these guidelines is needed.32 Our ethical analysis (see earlier under Ethics of Video Sharing in Plastic Surgery) and video sharing guidelines listed below therefore represent the first of their kind in the plastic surgery literature.

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Proposed Guidelines for Plastic Surgeons

As of yet, there exist no formal guidelines regarding video sharing on social media for plastic surgeons to follow. By means of our ethical analysis, we therefore propose a novel set of guidelines to protect patients, surgeons, and the public perception of our specialty:

1. Ask the patients whether or not they would like to have their operations videotaped and broadcasted on social media channels and obtain written consent should they choose to do so. Patient identifiers should be censored, including face, tattoos, identifying birthmarks, and demographic information.43 Should the patient agree to include his or her face or other protected health information, an additional provision on the consent document should be initialed. Full disclosure must be made, especially concerning the details of which exact social media platforms the video will be featured on. The patient may withdraw this consent at any time. Patients younger than 18 years should be treated as minors, in which case parental consent must be obtained unless the minor is deemed emancipated by court decision. It is advisable that plastic surgeons seek advice from a legal professional when drafting the consent form.

2. Let the patients know that they have the right to refuse, and that this refusal will in no way affect the quality of care they will receive. Plastic surgeons should never force or intimidate a patient into participating. Instruct the patients that they have the right to change their mind at any time and can always request to have their video deleted by the plastic surgeon.

3. Inform the patients that their images may be downloaded, saved, shared, or even manipulated by other social media users. Patients should further be warned that if they wish to have broadcasted media deleted, it will be removed from the plastic surgeon’s page(s) but other copies may exist, as these could have been obtained by other users. Furthermore, the patients must be informed that the terms of use policy of each social media platform varies and periodically changes and they would have to refer to the individual media platform for precise details.

4. Uphold standards of professionalism as advocated by the American Society of Plastic Surgeons Code of Ethics.52

5. To avoid possible increases in operative time, the plastic surgeon may wish to hire a designated and trained videographer. The plastic surgeon is accountable for overseeing all social media and marketing within their practice, and educating staff about maintaining a high level of professionalism and integrity.

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Limitations

This review is limited by a focus on the plastic surgery literature; thus, it did not delve into general reviews of video sharing and social media in the medical literature. It is also significantly limited by the paucity of available objective data in the surgical literature regarding the impact of plastic surgeon social media posts on the patient, as can be seen from the relative abundance of opinion articles. Future studies should investigate the impact of social media on plastic surgery patients from all angles (i.e., both harms and benefits).

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CONCLUSIONS

The impact of social media on the practice of plastic surgery remains largely unexamined, and the few publications that do exist focus on sites such as Facebook, YouTube, and Twitter, thereby ignoring newer and trendier platforms such as Snapchat and Instagram. This is surprising given that Snapchat is at the epicenter of much controversy with regard to broadcasting live operations and questionably inappropriate behavior in the operating room. To date, there have been no peer-reviewed articles discussing the ethical implications of such broadcasts. This analysis therefore fills an important gap in the plastic surgery literature by addressing these implications. Using the four principles of medical ethics, we discussed the ethical concerns and risks faced by patients with the use of social media video sharing platforms in plastic surgery. Adoption of formalized guidelines by governing bodies within our specialty is warranted, as are regulatory systems to uphold these standards. Comprehensive education on the risks and benefits of posting on social media is especially necessary for those who are less technology-savvy. In the interim, plastic surgeons may consider using the guidelines proposed here to avoid potential pitfalls while sharing videos of plastic surgery on social media.

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