Ethical and Regulatory Gaps in Aesthetic Medical Practice in Top Asian Medical Tourism Destinations

Abstract

Aesthetic medicine merges art and medical sciences, focusing on the modification and enhancement of physical appearance through surgical and non-surgical procedures. While it is not globally recognized as a medical specialty, aesthetic medicine has become a cornerstone of medical tourism in several Asian countries, including India, Malaysia, Singapore, South Korea, and Thailand. Despite its popularity, there is notable gap in literature concerning its ethical and regulatory perspective. This study aims to provide a comprehensive analysis of existing regulations and ethical considerations in aesthetic medicine within the context of the selected Asian countries. Given the field’s growth and its potential impact on both domestic and international health practices, this study is significant for healthcare providers, policymakers, and consumers alike. By identifying areas for improvement in current regulatory frameworks, the paper advocates for further examination to ensure that stakeholder rights and well-being are adequately protected.

Background

Aesthetic Medicine

Aesthetic medicine, a specialized field dedicated to modifying patients’ physical appearances, has seen significant growth in Asian countries including India, Malaysia, Singapore, South Korea, and Thailand. Within the burgeoning medical tourism industry, aesthetic medicine has carved a unique niche. As delineated by Irish medical doctor, Peter M. Prendergast, aesthetic medicine straddles “art and science” (Prendergast and Shiffman 2011). Unlike traditional therapeutic medicine, centers on disease treatment, aesthetic draws its terminology from a broader concept of “aesthetics.” Aesthetics is classically defined as the “appreciation of beauty” and extends to various realms such as object, attitude, experiences, and judgments (Eaton 1998). Procedures in aesthetic medicine aims to improve a patient’s appearance and, consequently, their perceived aesthetic quality (Prendergast and Shiffman 2011).

The complex concept of beauty as an ethical ideal was written by Heather Widdows (2020) in her book, Perfect Me: Beauty as an Ethical Ideal which examined societal pursuit of the “perfect” body which has evolved into an ethical ideal that is demanding on a global scale. Seeing beauty as an ethical ideal acknowledges the power and the influence that societal beauty norms have on individuals. It is not just a matter of personal preference but could affect someone’s self-esteem, mental health, and social standing. However, if beauty standard is understood as ethical ideals, then they can be scrutinized from a moral perspective, questioning fairness, inclusivity, and financial and psychological costs pursuing them.

Aesthetic medicine field gained widespread acclaim in the 1990s with the introduction of botulinum toxin, commonly known as “botox” by Jean and Alistair Carruthers. This advancement revolutionized the treatment of wrinkles and fine lines, garnering attention from various sectors, including entertainment (Carruthers et al. 1996). Further innovation came from Jeffrey Klein, who revolutionized lipoplasty by developing tumescent anesthesia (“using large volumes of dilute lidocaine and epinephrine infiltrated into subcutaneous fat”). This discovery made fat-removal procedure safer, more effective, and conducive to an office setting, thus broadening the field’s non-invasive offerings (Klein 1995).

Aesthetic Medical Specialty

Aesthetic medicine has evolved as an interdisciplinary domain intersecting with various other medical fields such as dermatology, plastic, reconstructive, and laser medicine including some surgical subspecialties like cosmetic surgery (Galęba and Marcinkowski 2015; Prendergast and Shiffman 2011). Procedures within aesthetic medicine can be delineated into two broad categories: those that serve purely for aesthetic purposes, such as facial and body contouring, and those intended for reconstructive or reparative outcomes (Shiffman and Di Giuseppe 2016). The spectrum of procedures encompasses both non-surgical anti-aging treatments like wrinkle correction and age spot removal and surgical interventions such as liposuction, breast augmentation, tummy tucking, and facial reshaping. Recent advancement even integrates stem cell technologies, manifesting in procedures like stem cell facelifts, stem cell facials, and stem cell–based botox (Prendergast and Shiffman 2011). Despite its less widespread recognition compared to traditional medical disciplines, aesthetic medicine garnered significant consumer interest, attributable in part to the transformative results it purports to offer.

Aesthetic Medicine and Medical Tourism

According to report by Nabeela Khan Inayati, India, Malaysia, Singapore, South Korea, and Thailand have emerged as leading nations in the global medical tourism industry, specializing in various aesthetic medical procedures (Inayati 2019). Table 1 elucidates a comparative analysis of costs of selected aesthetic medical procedures in these countries, as cited by a report by Health Tourism (2022).

Table 1.

Price comparison for selected aesthetic medical procedure

Procedure		Countries (cost based in US dollars)
	India	Malaysia	Singapore	South Korea	Thailand	USA	UK
Facelifts (rhytidectomy)	4000–5000	2500–3500	6500–7500	6000–6500	2400	7000–9000	11,000–12,000
Breast augmentation (mammoplasty)	3000–4500	3000–4000	7000–9000	7000	2600–3200	5000–8000	7000–8000
Liposuction (lipoplasty)	2000–3500	2000–3000	4500–5000	N/A	1200	4000–6500	5000–6000
Tummy tuck (abdominoplasty)	N/A	2000–2500	6000–6500	N/A	3000	4500–5500	6000–7000

Source: Health Tourism

Compared to the USA and the UK, the lower- and middle-income Asian countries such as India, Malaysia, and Thailand offer significantly more affordable rates for aesthetic medical procedure. For example, Thailand has become a popular destination for specialized treatments such as gender reassignment surgery costing between $12,000 and $54,000 compared to $300,000 if done in the USA (Zim and Jones 2021). This cost differential serves as a primary driver for medical tourism, alongside innovative experimental procedures.

While existing literature on aesthetic medicine primarily focuses on technological advancements and patient satisfaction (Carruthers et al. 1996; Klein 1995), scholarly investigations into the ethical and regulatory concerns on aesthetic medicine are limited, serving the focal point of the present study. In 2010, Mousavi argued that ethical issues within this domain stems from dual roles of doctors—both as artists in aesthetic medicine and as healers in traditional medicine (Mousavi 2010). He posits that the four principles of biomedical ethics—respect for patient autonomy, beneficence, non-maleficent, and justice—as articulated by Beauchamp and Childress (1983), providing an apt ethical framework for this burgeoning field. However, the application of these principles to aesthetic medicine raises complex questions, particularly concerning the ethical implication of marketing practices and the capacity for adolescent patients to make informed decisions.

Most aesthetic medical procedures are predominantly offered by private healthcare entities such as clinics and hospitals rather than public or government-funded institution. This predominance raises ethical concerns since doctors in aesthetic medicine can directly profit from societal conception of beauty, potentially commodifying human worth (Berkowitz 2017). Moreover, the commercial aspect of these private medical providers could lead to the exploitation of vulnerable individuals through exaggerated claims and advertisements that prey on societal norms (Wiesing 2009). Several scholars have discussed the ethical implication of beauty standard, and although there are different perspectives, there is still much debate. Wolf (2013) who published a book, The Beauty Myth, explored societal standard of beauty which measure as a form of social control, particularly over women. But Jean Kilbourne is one of the most notable experts known for her work on the representation of women in advertising through her “Killing Us Softly” documentary series. She began exploring the link between advertising and public health issues, such as violence against women, eating disorders, and addiction which she tried to prevent through a movement promoting media literacy (Lazarus and Wunderlich 1979). However, the ethics of enhancing ones’ features to conform to societal beauty norms are beyond the scope of this article.

From a regulatory perspective, a study by Harold Tan from Singapore’s Ministry of Health called for governance in the realm of aesthetic medicine, emphasizing the risks involved in minimally invasive procedures carried out by general practitioners (Tan 2007). Scholars and experts like Spear (2010) and Marinelli et al. (2016) have also directed attention to ethical considerations in aesthetic medicine, including consent and risk management. Moreover, published works have increasingly incorporated ethical consideration, urging practitioners to be cognizant of ethical challenges, including the exploitation of vulnerable populations (Maio 2011; Prendergast and Shiffman 2011; Wiesing 2009). A paper by Bryan C. Mendelson critiqued the ethical and moral implications of media advertising within the industry, which was later examined in a follow-up paper by Atiyeh and Ibrahim (2020) (Mendelson 2008). These papers questioned the moral integrity and virtue of aesthetic plastic surgeons, particularly in the context of media advertising.

Despite the emerging literatures addressing the ethical considerations in aesthetic medicine, there remains a significant gap in the regulatory discourse, particularly within major Asian medical tourism countries, namely India, Singapore, Thailand, Malaysia, and South Korea. This study aims to fill in the gap by examining the ethical and regulatory challenges exclusive to aesthetic medicine in these countries. Given the sector’s unique nature, exploring these challenges is critical to ensure accountability and safeguarding stakeholders’ rights and well-being.

Methods

This exploratory study employed qualitative methodologies to investigate the ethical and regulatory landscape of aesthetic medical industry, with a focus on five selected Asian country: India, Malaysia, Singapore, South Korea, and Thailand (Burnard et al. 2008; Patton 2014). While there are a range of destinations globally, Asia is a major medical tourism destination. These five countries, in Asia, have widely promoted aesthetic medicine and medical tourism internationally (Kim et al. 2019). To gather pertinent data, a comprehensive literature review was conducted. Journal articles were identified through keywords (“aesthetic medicine” AND “ethic*” AND “regulat*”) in academic databases such as Scopus and Web of Science (WoS). These keywords are crucial to learn first, what are published article have reported thus far concerning aesthetic medicine and its ethical perspective, and second, to consolidate this information into one comprehensive work, and finally, to add more elements of the regulatory concerns that often underreported.

Additionally, government documents—including laws, circulars, and guidelines—were retrieved from official government portals to provide legal and administrative context. Qualitative content analysis served as the primary analytical tool, enabling the systematic interpretation of gathered data to answer specific research questions (Hsieh and Shannon 2005; Pautasso 2013). This approach relies on the researchers’ subjective interpretation to unearth new and insightful information about the ethical and regulatory dimensions of aesthetic medicine and significantly aligned with the choice of data. The study will answer two main research questions: (1) “Is aesthetic medicine effectively regulated in India, Malaysia, Singapore, South Korea, and Thailand?” and (2) “What are the consumer and patient implications based on the existing regulatory practices in India, Malaysia, Singapore, South Korea, and Thailand?.” These guiding questions proved critical in achieving its objective (Hsieh and Shannon 2005). In addition to the literature and legal documents, reports on significant mishaps and botched aesthetic medical procedures within the aesthetic medical industry in the selected countries were reviewed and documented. By triangulating these data, the empirical evidence for the current aesthetic medicine regulation and its practice in these countries are established.

Result

The aesthetic medicine industry offers a diverse array of procedures for individuals seeking to modify their appearance. For instance, a 29-year-old Chinese actor, who underwent multiple procedures since the age of 18, had been lauded as a “medical marvel,” transformative potential of aesthetic medicine (Khoo 2022). Beyond cosmetic enhancement, the industry provides reconstructive options for individuals disfigured due to accidents or and mutilated by a wild animals or human attacks. Although the ethics of enhancing ones’ aesthetic qualities through medical procedures are not the focus of this article, it does investigate the ethical implication arising from current regulatory framework. This inquiry is facilitated by examining reports of mishaps pertaining to aesthetic medical procedures in five popular Asian destinations for medical tourism—India, Malaysia, Singapore, South Korea, and Thailand. Concurrently, the regulatory landscape of aesthetics medicine in these countries is scrutinized to understand its impact on patient safety and ethical conduct. While the findings of this study proved valuable to understand the current ethical and regulatory concerns of aesthetic medicine in Asia, two key limitations are as follows: one, the keywords use that could have resulted in the exclusion of other but relevant articles and second, the time taken to analyze the legal documents as well as the news articles and literatures to triangulate and cross-check the details in a coherent manner.

Reports of Botched Procedures and Misconducts

Aesthetic medicine, encompassing both plastic and reconstructive procedures, has offered transformative possibilities for individuals seeking to improve their appearances or remedy disfigurements caused by accidents. While there are numerous accounts highlighting the positive impact of these procedures on individuals’ lives, it is imperative to acknowledge the instances of unsuccessful or “botched” procedures. Table 2 describes reported incidents from 2010 to 2022 in the five Asian countries under study: India, Malaysia, Singapore, South Korea, and Thailand. Of the 12 listed, seven resulted in-patient fatalities attributable to medical complication and negligence. A variety of factors have been identified as contributing to these unfortunate outcomes. These factors include misleading advertisements by aesthetic medical providers that promise unrealistically exceptional results, the involvement of unqualified or unlicensed doctors, the inadequate postoperative care particularly for minimally invasive and invasive procedures, and the absence of robust regulatory frameworks for patient safety.

Table 2.

Reports of botched aesthetic medical procedures

Year	Location	Incident reported	Ethical concern
2010	Thailand (foreign national woman)	A bad nose job that resulted in the woman being unable to breath easily through one nostril (Head 2015)	Misleading marketing practice or false advertisement
2014	Malaysia (Australian man)	A 31-year-old man died due to blocked lung artery caused by blood clots days after undergoing liposuction, abdominoplasty, and upper lip augmentation (Brender 2017; Malaysiakini 2017)	Inadequate postoperative care
2014	Thailand (British woman)	A 24-year-old woman paid £2000 for a buttock’s augmentation (silicone implant) which became infected, and after returning for a second surgery, she died which under anesthetic (International Medical Travel Journal 2014)	Unlicensed practitioner
2014	South Korea (local woman)	A 49-year-old woman sought 15 cosmetic surgeries that cost close to $28,000 to correct her nose but was left with multiple medical problem such as unable to close her eyes or stop her nose from running (Park 2014)	Lack of specialization
2015	Thailand (Australian woman)	A young Australian woman was left permanently scarred due to botched cosmetic surgery; breast lift and augmentation and extended tummy tuck which cost up to $16,000. She was given the wrong implants (NZ Herald 2018)	Misleading marketing practice or false advertisement
2018	Singapore (local man)	A 44-year-old man died during a liposuction procedure after the doctor administered sedative improperly leading in the man being left attended and unable to breath (Tang 2018)	Medical malpractice and dishonesty
2020	Malaysia (local woman)	A 23-year-old woman died due to a MYR2500 liposuction that gone wrong (David 2020)	Ambiguity in practitioner’s qualifications
2020	South Korea (Hong Kong woman)	A 34-year-old heiress died while getting a liposuction and a breast augmentation which led her to a coma due to the sedative administered improperly (Lapin 2020)	Uncertified surgeon and absence of an anesthetist
2021	South Korea (local man)	A 24-year-old man died seven weeks after an aesthetic procedure to make his jaw more slender, during which time become unconscious after bleeding out (Seo and Hollingsworth 2021)	“Ghost doctor” issue
2022	India (local woman)	A 21-year-old Indian actress died due to complication during a botched liposuction procedure (Karthik 2020)	Unlicensed clinic
2022	Malaysia (local man)	A man sued his aesthetic doctor for MYR2.7 million due to a botched nose job that left him deformed (Hariz 2022)	Misleading guarantees
2022	Malaysia (local transgender person)	A cartilage graft rhinoplasty that cost MYR13,466 which left her with a deformed nose (Zack 2022)	Procedure conducted by a foreign doctor

Regulation on Aesthetic Medicine

The regulations governing aesthetic medicine in India, Malaysia, Singapore, South Korea, and Thailand are outlined in Table 4 (see Appendix). Interestingly, findings indicate that none of these countries enacted specific laws or legislation dedicated solely to regulating the field of aesthetic medicine. However, various aspects of the industry such as clinics and products registration (covering botox, fillers, and implants) do fall under the purview of existing legal framework.

Table 4.

List of regulations on aesthetic medicine for selected Asian countries

Countries	Laws, legislation, policies, and guidelines on aesthetic medicine	Other relevant guidelines and regulations	Observation and analysis
India	1. Medical Device Rules India, 2017: Classification of Medical Devices Regulations and Regulatory Approval for Registration	2. Drug and Cosmetics (Amendment) Bill, 2016 3. Guidelines on Registration of Import of Cosmetics 4. Clarification for Import and Registration of Cosmetics 5. Classification of Cosmetic Raw Materials and Adjuncts Part 1 & Part 2	• No. 1 includes fillers and breast implants which are regulated as medical devices • No. 2–5: Mostly on the importation of particular drugs (which includes manufacturing, sale, and distribution) (also on Ayurvedic /Siddha/Unani drugs) • No explicit stipulations on aesthetic procedures • There is no specific regulation for aesthetic medicine or medical tourism • There is an accreditation board
Malaysia	1. Guideline on the Ethical Aspects of Aesthetic Medicine Practice (Ministry of Health 2020) 2. Medicine Advertisements Board Regulations 1976	3. Private Healthcare Facilities and Service Act 1998 and Regulations 2006 4. Medical Act 1971 (Amended 2012); Medical Regulations 2017 5. Poison Act 1952 (Revised 1989) 6. Sale of Drugs Act 1952 (Revised 1989) 7. Control of Drugs and Cosmetics Regulations 1984	No. 1 guideline updated in 2020 (previous edition 2013) No. 2–4 are more towards general medical practice and without any explicit mentions towards aesthetic medicine No. 5–7 are more on regulation of aesthetic medical compounds
Singapore	1. Guidelines on Aesthetic Practices for Doctors (Singapore Medical Council 2016a) 2. Health Products (Medical Devices) Regulations 2010 3. Private Hospitals and Medical Clinics Act 1980	4. Poison Act (1938) 5.  Ethical Code and Ethical Guidelines (Singapore Medical Council 2016b) 6. Handbook on Medical Ethics (Singapore Medical Council 2016c)	No. 1. includes regulation on Botulinum toxin (botox), and that only doctors are allowed to perform aesthetic medical procedures. The application form needs the medical number (of the doctor) No. 2 regulates all medical devices including breast implants No. 3 is more towards registration, licensing, and controls of clinics or hospitals (offering aesthetic medical procedures) No. 4 is more for license and registration of some aesthetic compounds that can be considered poison No. 5 and 6 outline challenges in medical practice, advertising of medicine and use of social media, including rising aesthetic medicine
South Korea	1. Cosmetics Act 2018 2. Cosmetics Regulatory Framework 2019 3. Medical Services Act 2016	4. Public Health Control Act 2016 5. Medical Devices Act 2016	No. 1 and 2 are relevant for cosmetics According to No. 3, any licensed medical practitioner can perform any medical practice including aesthetic procedures No. 4 focuses more on the establishment, the licensing, and administrative violations No. 5 does not include any aesthetic-based products. It only recognizes those used for treatment
Thailand	1. Medical Devices Act (Issue 2) B.E 2562 (2019)	2. Cosmetics Act B.E. 2558 (2015)	No. 1 has no specific stipulations on aesthetic medicine No. 2, there is only mention of licensing and advertisements

Similarly, most countries appear to rely on existing laws and regulations to oversee medical tourism. These laws often focus on foundational medical practices, such as the licensing of doctors’ and legal registration of private clinics and hospitals. The implicit assumption seems to be that these general regulations are adequate for ensuring ethical practices in both the aesthetic medicine and medical tourism sector. However, aesthetic medicine raises unique ethical and regulatory issues that not fully addressed by existing laws.

For example, current regulations may not adequately cover aspects like informed consent, risk associated with undergoing multiple minimally invasive procedures simultaneously, follow-up care protocols, and the specific qualifications required for practitioners administering both minimally and fully invasive aesthetic procedures. These gaps highlight the need for a more targeted examination to ensure these practices adhere to an ethical code of conduct.

India

In India, the regulation framework for aesthetic medicine is a complex amalgamation of several laws and guidelines, each governing different aspects of medical practice and healthcare. The Medical Device Rules, 2017 specifically addresses the registration and governance of breast implants and fillers (such as botox). However, this legislation does not explicitly cover other aesthetic procedures like facelifts, tummy tuck, and liposuction. Complementing this, the India’s Drugs and Cosmetics (Amendment) Bill, 2016 offers further regulatory guidelines concerning the importations, classification, and registrations of cosmetics ensuring safer distribution and sales. This act has been foundational in ensuring the quality of substances used in aesthetic medicine but does not offer detailed guidelines on the procedures themselves.

Additionally, the Indian Medical Council (Professional Conduct, Etiquette, and Ethics) Regulations, 2002 sets the ethical and professional standards for practitioners, including those in the field of aesthetic medicine. These regulations require that all practitioners adhere to a strict code of conduct and ethical guidelines, providing a level of assurance regarding the qualifications and ethics of the professionals involved. The Clinical Establishments (Registration and Regulation) Act, 2010 mandates the registration and standardization of all clinical establishments, including those offering aesthetic medicine services. This helps to ensure that all establishments meet baseline criteria for infrastructure, staff qualifications, and patient safety protocols.

Despite this layered regulatory framework, there are still gaps, especially concerning specific aesthetic medical procedures and their associated ethical considerations. As a unique area of medicine, aspects of aesthetic medicine such as informed consent, the risks of undergoing multiple minimally invasive procedures simultaneously, follow-up appointment policies, and the qualifications of experts administering non-invasive, minimally invasive, and invasive procedures require further scrutiny to align them with ethical best practices.

Malaysia

In Malaysia, the regulatory landscape for aesthetic medicine is shaped by a number of legal instruments and guideline, each contributing to different facets of the practice. The Guidelines on the Ethical Aspects of Aesthetic Medical Practice (Ministry of Health 2020) first published in 2013 serves as a cornerstone document. This guideline depicts the types of procedures that both specialist and non-specialist are authorized to conduct in the field of aesthetic medicine. However, this standalone guideline is augmented by a number of other general laws that indirectly influences the aesthetic medicine sector. The Private Healthcare Facilities and Services Act 1998 and Regulations 2006 govern the registration and functioning private aesthetic medical clinics and establishments, as well as the range of services they are permitted to offer. The Medical Act 1971 (Amended 2012) along with the Medical Regulations 2017 mandates that all medical practitioners, including those specializing in aesthetic medicine, be registered and licensed to practice. This ensures a basic level of professional credibility and ethical adherence. Chemical compound and cosmetics integral to aesthetic medicine are overseen by a trio of laws: the Poison Act 1952 (Revised 1989), which regulates the importation, possession, manufacture, compounding, storage, transport, sale, and use of poisons; the Sales of Drug Act 1952 (Revised 1989), which regulates of sales of any drugs; and the Control of Drugs and Cosmetics Regulations 1984, which stipulates that no one may manufacture, sell, supply, import, and possess any cosmetics unless they are officially notified. Despite the presence of these various regulations and acts, there is a gap in terms of dedicated legislation that exclusively targets aesthetic medicine and its particularly ethical and professional challenges, including issues related to medical tourism. Existing laws and guideline often provide a general framework without offering explicit provisions for the unique concerns of aesthetic medicine, such as qualifications for performing specific procedures, false advertising, informed consent, postoperative care, and malpractice.

Singapore

In Singapore, the Guideline on Aesthetic Practices for Doctors (Singapore Medical Council 2016a) serves as the principal documents outlining the approved procedures that both specialist and non-specialist doctors in Singapore can perform in the realm of aesthetic medicine. This is somewhat similar to Malaysia’s guideline, delineating the types of procedures permissible within aesthetic clinics and hospitals. Additionally, the Health Products (Medical Devices) Regulations 2010 governs the use of implantable devices including but not limited to heart valve, artificial heart, and ventricular system and including breast implants. This bears resemblance to India’s Medical Device Rules, 2017, which similarly regulates certain implantable devices. While there is legislation governing medical devices and poisons, there is not a focused legal framework that addresses the protection of consumers specifically in the context of aesthetic medicine, particularly concerning false advertising and malpractice. The legal framework for aesthetic medicine in Singapore includes the Private Hospitals and Medical Clinics Act 1980 and the Poison Act 1938. These acts govern the license and registration of private medical clinics and hospitals, as well as the regulation of certain chemical compounds used in aesthetic medicine that may be considered as poison.

Further enriching this regulatory landscape is the Singapore Medical Council’s (2016b) Ethical Code and Ethical Guidelines, along with the Handbook on Medical Ethics (2016c). These documents tackle a broad spectrum of issues ranging from the general challenges in medical practice to the advertising of medical services and the responsible use of social media, but they neglect the address the ethical challenges posed by aesthetic medicine such as psychological impact, informed consent, and postoperative care. They also address emerging trends and concerns in the rapidly evolving field of aesthetic medicine.

South Korea

In South Korea, the regulation of aesthetic medicine largely falls under general medical law rather than specific legislation dedicated to aesthetic procedures. Key regulations include the Cosmetics Act 2018, Cosmetics Regulatory Framework 2019, Medical Services Act 2016, and Public Health Control Act 2016. The Cosmetic Act primarily focuses on products designed for skincare, cleansing, and beautification and does not encompass medical aesthetic products such as botox, fillers, and implants. Similarly, the Cosmetic Regulatory Framework adheres to a broad scope of consumer-level cosmetic products rather than medical-grade aesthetic solution. The Medical Devices Act 2016 is more comprehensive, covering a wide range of medical services but not specifically addressing aesthetic practices but it not exclusive to them, creating a regulatory gap for this specialized field. The Public Health Control Act 2016 aims to improve and protect public health but lacks specific guidelines on aesthetic medical procedure. It generally governs healthcare facilities and services, not expressly dealing with aesthetic medicine. The Medical Devices Act 2016 also misses the mark when it comes to regulating aesthetic-based medical products. The Act is restricted to devices used for diagnosis, treatment, prevention of diseases, and other medical purposes but exclude products commonly used in aesthetic medicine like implants and injectables. Unlike the regulatory frameworks in countries like India, Malaysia, or Singapore which include specific guidelines or acts that in some way cover aesthetic medicine, South Korea’s laws are not as encompassing in this regard. This leaves a regulatory vacuum that could potentially impact the safety and efficacy of aesthetic medicine medical practices within the country.

Thailand

In Thailand, the regulatory framework for aesthetic medicine remains largely general, without dedicated laws or guidelines specific to this medical subfield. One of the key pieces of legislation is the Medical Devices Act (Issue 2) B.E 2562 (2019), an update from the 2008 version. This Act governs the licensing and registration of establishments as well as the registrations and labeling of medical devices. These devices are broadly defined to include appliances, mechanical tools, injectable objects, and solutions used for tests, among others. While this broad definition could encompass various components commonly used in aesthetic medicine—such as fillers and implants—the Act does not explicitly list them. This creates ambiguity in terms of what aesthetic medical devices are regulated and to what extent. The Act also mandates that any advertising related to medical devices accessible to the public must receive prior approval from regulatory authorities, a clause that impacts the aesthetic medicine sector. But there is no specific guidance on advertising in the realm of aesthetic medicine, which has psychological implications.

Additionally, the Cosmetics Act B.E. 2558 (2015) provides some regulatory oversight over aesthetic medicine by governing cosmetic products. These are defined as compounds and preparations for external application on human body. However, the Act explicitly excludes ornaments and clothing categorizing them as accessories outside the human body. The narrow definition leaves a regulatory gap for products or devices that may not fit within these categories but are nonetheless integral to aesthetic medical procedures. Neither the Medical Devices Act nor the Cosmetics Act specifically addresses aesthetic medicine, leaving a void in oversight for procedures such as botox injections, dermal fillers, or surgical interventions like liposuction or facelifts. Overall, while Thailand does have general regulatory frameworks that could potentially be applied to aesthetic medicine, the absence of specific guidelines or statues focusing on this area results in regulatory gaps and ambiguities such as standard for postoperative care and protection against malpractice and negligence.

Discussion

Over the past decade, numerous reports have highlighted unintended outcomes and complications resulting from botched or unethical aesthetic medical procedures, as detailed in Table 2. These adverse events have led to patients’ dissatisfaction, physical disfigurement, and, in some cases, loss of life. While this article specially examines the states of aesthetic medicine in five key Asian countries, the issues are not unique to this region and are similarly observed in other highly developed countries like the UK, USA, or Australia. Even procedures considered to be minimally invasive, such as liposuction, can lead to complications, when performed by unqualified individuals, the consequences can be devastating.

Factors causing Botched Procedures and their Ethical Issues

Qualification and the Code of Ethics of Aesthetic Medical Experts

A thorough examination of 12 cases, as outlined in Table 2, identifies the qualification of the practitioners as a critical factor contributing to mishaps and unintended outcomes in aesthetic medical procedures. There are undeniable risks when unqualified non-medical personnel lacking proper medical knowledge undertake intricate procedures like liposuction without adequate training for managing complications. This observation is consistent with previous research by Tan (2007), emphasizing that the majority of mishaps occur during minimally invasive procedures, a trend not exclusive to the five countries examined in this article but also prevalent in highly developed nations. Advertisements often emphasize the expertise of the medical professionals performing these procedures, sometimes misleadingly using the prefix of “Dr” to imply medical qualifications. However, as highlighted by David (2020), even general practitioners without specialized training in aesthetic medicine can unknowingly cause harm when administering treatments like dermal fillers or liposuction. But unlike aesthetic medicine, for conventional clinical practices, there are platforms for patients to complaint, and as a licensed practitioner involved, there are consequences. In addition, the absence of an anesthesiologist to administer the proper dosage of anesthesia during these procedures has also been fatal in several cases, as indicated by Tang (2018). The presence of unlicensed practitioners, including foreign doctors operating without license, calls into question the ethical integrity of the medical facility and its adherence to the principle of non-maleficence, as pointed by Zack (2022), which is rather common within aesthetic medical practice.

Ethically, medical practitioners take the Hippocratic Oath as a moral guide, pledging to treat patients with care and to do no harm. When this pledge is violated, it contravenes the core principle of modern medical ethics: autonomy, justice, non-maleficence, and beneficence, as discussed by Parsa-Parsi (2017). These principles also serve as the foundation of “principlism,” a framework used in bioethics that encompasses both basic and global applications, according to Beauchamp and Rauprich (2016). Despite the exception of self-regulation, the aesthetic medical industry has shown limitations in upholding ethical standards, as noted by Collier (2012). Professional autonomy in medical practice carries with it a responsibility for self-regulation, requiring greater effort to understand and mitigate the factors leading to medical mishaps (Collier 2012). However, the unique nature of aesthetic medicine, along with inconsistent qualifications and practices among its experts, has made effective self-regulation a daunting challenge, as articulated by Tseng (2020).

At present, many countries globally have not implemented specific laws or legislations to govern aesthetic medicine or medical tourism (Gopalan et al. 2021). While some nations have drafted guidelines to address the unique challenges posed by aesthetic medical practice, many other have not. This legislative gap creates opportunities for exploitation and increases the risk of unintended incidents. Among the five Asian countries in discussion, only Malaysia and Singapore have developed explicit guidelines pertaining to aesthetic medicine. Recognizing the growing number of complaints and the field’s increasing importance, both nations have included requirements for specific aesthetic medical speciality qualifications for practitioners within their guidelines (Ministry of Health 2020; Singapore Medical Council 2016c).

In contrast, India, South Korea, or Thailand does not have such guideline, leaving the practice of aesthetic medicine in these countries largely unregulated and fraught with risks. The absence of explicit criteria or qualifications for practitioners means that reports of botched procedure are likely to rise without mitigation plans. Meanwhile, many countries rely heavily on the existing laws and acts, believing them to be sufficiently comprehensive for governing aesthetic medicine as well as medical tourism (Gopalan et al. 2021). However, this approach has limitations. Existing Cosmetics Acts and Medical Device Acts within these five selected Asian countries tend to focus on specific area such as the registration of medical devices like cardiac stents, pacemakers, and inter-uterine contraceptive. They often neglect distinct aesthetic-specific devices and treatment such as botox, fillers, and implants. Additionally, the qualifications or trainings of the practitioners conducting these aesthetic procedures go largely unnoticed, despite the widespread promotion of these treatments in magazines and social medias. This lack of attention to practitioners’ qualifications underscores the urgent need for comprehensive regulation to ensure patient safety and ethical practices within the field of aesthetic medicine.

Code of Conduct of Aesthetic Medical Clinics

Aesthetic medical clinics and hospitals fall under the purview of private healthcare regulations in many countries, including the five Asian nations examined in this study. Aesthetic medicine is often a distinct medical speciality separate from general therapeutic care, usually set up as private practices by individual experts who stand to profit directly. Interestingly, these practices can also operate as a “wellness center” in malls without registering as a healthcare provider. Additionally, some operate illegally, such as those functioning out of residential space (i.e., woman operating in a flat in Singapore) or under false pretenses, claiming to offer only non-invasive procedures which includes dermal fillers, facials, chemical peels, and laser skin resurfacing treatment. It is not inconceivable that some of these centers may also offer minimally invasive procedures without proper approval, an action that is illegal but yet not uncommon. Such practices often skirt mandatory approval processes, which include site visits and inspections to avoid bureaucratic paperwork.

While some clinics operate within legal bounds, being properly registered and licensed, others are willing to employ unlicensed and unqualified experts. These clinics often utilize unhygienic methods, and procedures, in direct violation of medical code of conduct. In the medical field, a code of conduct outlines ethical rules and behavior expected of physicians, setting the priorities of their professional work and establishing high moral principles in their interaction with patients, colleagues, and the broader community. While the exact language may differ from country to country, these codes prioritize the health and well-being of patients and their family under a physician’s care. In this case, it not only the clinic’s code of conduct is being violated but also the ethical integrity of the expert who perform these illegal procedures. Such actions by a minority of unscrupulous entities cast doubt on the integrity of the entire aesthetic medical industry, which is both unfortunate and unfair (AAD 2018; AMA 2022).

Indeed, while it is a grave concern, one must also consider lack of awareness among clinics about the implication and risks of their actions. Such behavior not only violates the principle of non-maleficence principle (the obligation to do no intentional harm) but also indicates a failure to conduct a comprehensive risk–benefit analysis. The analysis should include a moral evaluation guided by principles of justice. Offering an expensive yet subpar service constitutes an injustice to the consumer and exploits vulnerable individuals, who may not fully grasp the potential risks involved. This situation calls into question the necessity for a more robust and safer overall system—both in practice and regulatory—to minimize instances of errors and negligence. Instituting a transparent relationship between consumers and practitioners could help to address the underlying biases and discrimination against vulnerable patients (Jean-Pierre 2022). For example, standardized protocols could be developed to ensure that informed consent is genuinely informed, reducing exploitation and the risk of malpractice. Moreover, establishing clear channels for accountability and redress can further strengthen the system’s integrity.

By taking these steps, we could work towards restoring public trust not just in the field of aesthetic medicine, but in the healthcare system as a whole. Recent studies like the one by Jean-Pierre (2022) indicate the urgency of this reform, emphasizing that time is of the essence to prevent further incidents and regain the confidence of the public.

Direct to Consumer Advertisement and Overpromise

Aesthetic medical procedures are frequently advertised directly to consumers through various channels; digital platforms like emails, social media, and online magazines; print media like magazines and flyers; outdoors advertising such as posters and banners; and broadcast mediums like television and radio. While these advertisements do reach the public directly, their content often leans towards being misleading and overly promising. They commonly feature vague description of the procedures, credential of the “experts”—sometimes touting affiliations with Ivy League universities—and images of models and celebrities who embody societal standards of beauty. These ads often include before-and-after pictures and testimonials from purportedly satisfied customers, making it difficult to ascertain the veracity of the claims being made.

While the procedures being advertised may have its own set of risks (i.e., the authenticity and reliability), the qualification of the professionals promoting them is equally risky. These advertisements sometimes claim that the practitioners have trained in prestigious medical schools and are board certified specialized, thereby gaining trust of consumers who have limited knowledge about the specialized training required for such procedures. This is particularly concerning because it is challenging to differentiate between practitioners who adhere to ethical code of conduct and those who do not. This kind of irresponsible advertising unfairly tarnishes the reputation of the aesthetic medical industry as a whole (Collier 2018).

It is worth noting that all practicing physicians are expected to adhere to the ethical codes, upholding the high standards and integrity of their profession. When these codes and standards are violated, it is a clear indication that the practitioner’s actions are not in the best interest of their patients. Although some jurisdictions like Singapore have addressed the issue of direct-to-consumer advertising by stipulating that advertisements must not be misleading and that the procedures should be carried out in appropriate clinical settings, many countries have yet to acknowledge its severe consequences of such practices by incorporating them into formal guidelines.

Meanwhile, the format of direct-to-consumer advertisements often allows advertisers to selectively include details while omitting others, such as the license and registration numbers of the clinics or wellness center involved. The general public usually does not take the additional steps of verifying whether these establishments are licensed or advertised information is accurate. Though some guidelines and legislation, as in Singapore and Malaysia, mandate that all medical-related advertisements receive approval from regulatory bodies, this is not universally adhered to (Ministry of Health 2020; Singapore Medical Council 2016a). Table 3 provides an overview of the acts and legislation related to medical advertising in the selected Asian countries, most of which require some form of pre-approvals before they are disseminated, except for the Indian Drugs and Cosmetics (Amendment) Bill, 2016 that does not explicitly require a pre-approval.

Table 3.

Laws and legislation related to aesthetic medical advertisements

Countries	Acts or legislations related to medical advertisement (closest to aesthetic medicine)
India	Drugs and Cosmetics Act (Amendment) Bill, 2016
Malaysia	Medicine Advertisements Board Regulations 1976
Singapore	Private Hospitals and Medical Clinics (Advertisement) Regulations 2019
South Korea	Pharmaceutical Affairs Act 2016
Thailand	Medical Facility Act B.E. 2541 (1998) (also known as the Sanatorium Act)

In 2017, Nagpal, serving as the chairman and managing director of the Medicos Legal Action Group in India, challenged the practice of aesthetic surgeons advertising their services in his article, “Should Advertising by Aesthetic Surgeons be Permitted?”. According to the Indian Medical Council Act, 1956 (Professional Conduct and Ethics) Regulations, 2002, doctors are generally prohibited from advertising to solicit patients (Indian Medical Council, 2002). However, it remains unclear whether this prohibition extends to the field of aesthetic medicine, much of which operates within the private sector (Nagpal 2017). In the case of Indian Medical Association vs V.P. Shanta, it was established that medical service offered by physicians fall under the scope of Consumer Protection Act (Desai 2020). This regulatory ambiguity is not confined to India; it is a widespread issue in countries that have similar laws. In India, there is no explicit requirement for pre-approval evaluation process for any advertisement, highlighting a regulatory gap that needs addressing. Even in countries that require such pre-approvals, enforcement is often reactive; authorities act only when there are whistle-blowers or formal complaints. Therefore, comprehensive studies urgently needed to evaluate the impact “false advertising” involving aesthetic medicine. Such research could provide policymakers and regulators with the date necessary to understand its consequences and formulate appropriate regulations (The Star 2021).

In summary, while some countries have made progress in developing guidelines and legislation concerning medical advertising, there remains a significant disparity. This gap puts the public at risk, as they may be exposed to misleading or incomplete information. A more coordinated and stringent regulatory approach to medical advertising, particularly in the specialized area of aesthetic medicine, is urgently needed.

Variability in Standards of Care in Aesthetic Medicine

The shortcoming in aesthetic medicine is not trivial; they pose serious risks that warrant immediate and well-thought action. Despite the gravity of these issues, current regulations in many countries either inadequately address or entirely neglect them. A call for reform is imperative to mitigate these risks. Beyond the concerns already discusses, there exists several under-recognized challenges that are unique to aesthetic medicine. It is crucial to distinguish between the standard of care in general medical practice, which primarily focus on healing, and those in aesthetic medicine, which often aim at enhancement. Several aspects are notably distinct in aesthetic medicine, include but not limited to (1) informed consent, (2) postoperative care or follow-up policy, (3) patient abandonment, and (4) malpractice and negligence. Currently, none of these critical aspects is thoroughly covered in existing guidelines or legislation. Where they are mentioned, is it often in cursory manner that lacks specific details.

Informed consent serves as a keystone in both clinical practice and research. It functions as a dialogic process between physicians and patients, facilitating the latter’s informed and voluntary agreement to undergo a medical procedure or participate in research. According to traditional ethical guidelines, informed consent usually involves three steps: assessing patient competency, disclosing relevant information, and ensuring that the patient’s decision is voluntary (Nejadsarvari and Ebrahimi 2014). Whether for therapeutic intervention, emergency treatment, life-saving procedures, or aesthetic medicine, the basic tenet of informed consent remains consistent. The principle of patient autonomy is the intrinsic right to make rational decision based on self-determination (Varkey 2021).

However, the application of informed consent diverges significantly when comparing therapeutic procedures to aesthetic ones. For example, in a life-threatening situation like appendicitis, the physician must clearly outline the urgency, risks, and benefits, given the immediate implications for the patient’s health. Conversely, aesthetic procedures like facelifts are typically elective, involving different motivations and expectations from the patient. The elective nature of aesthetic medicine introduces unique ethical challenges. Physicians may sometimes withhold information to avoid discouraging a patient from undergoing an elective procedure, which raises concerns about justice and informed decision-making. The informed consent process in this context may lack a discussion about the necessity of the procedure or the consequences of opting out.

The pressing question is as follows: should informed consent in aesthetic medicine be approached the same way as in therapeutic medicine? Given its unique nature, informed consent in aesthetic medicine may require a more tailored approach. This is especially pertinent when patients might be making decisions influenced by social or psychological pressures rather than a thorough understanding of the procedure and its risks (Kapoor 2015).

Research indicates that patients are often committed to aesthetic procedures with limited knowledge of associated risks or complication (Tan 2007). This lack of understanding can lead to adverse events and subsequent blame towards the healthcare providers. It is important to educate public to thoroughly research any aesthetic medical procedures they consider undergoing. This includes understanding the specific procedure, potential side effects, the credentials of the medical professional involved, and the legitimacy of the clinic. Patients, who opt for multiple procedures at one (i.e., such as liposuction, tummy tuck, face reshaping, and neck augmentation), for example, in the context of medical tourism, require special attention. While some clinicians argue that combining procedures is cost-effective and convenient (Kremer 2014), it increases the risk of complications due to prolonger anesthesia and surgical times. While recovery after one procedure can be tolerable, it can be more painful and much longer for those that had done multiple procedures. In the case of an Australian man who died in Malaysia in 2014, due to “deep vein thrombosis” (blood clots blocking veins), after two surgeries at the “boutique medical center” in the span of five days, is one such case. It was found that he was administrated below recommended level of anti-blood clot medicine (Malaysiakini 2017). Therefore, providing patients with a clear description of how the procedure is done (i.e., video), some facts on body’s healing mechanism and some common complications, would help patients in making informed decision.

Typically, in medical practice, postoperative care or “follow-up” is when patients are given follow-up appointments to monitor patients’ recovery. However, in aesthetic medicine, especially for medical tourists, this can be problematic. Additional visits may incur extra costs and may not be feasible for patients who need to return to their home country. Reports suggest that some aesthetic clinics fall short in providing adequate postoperative care. Failure to offer care, include neglecting to monitor for potential complications, can be classified as medical abandonment. This is a form of medical malpractice and represents a breach of duty (McQuoid-Mason 2015; Sacopulos 2015). To mitigate these challenges, regulators should aim to empower the public with comprehensive information about aesthetic medical procedures. Given the unique concerns in aesthetic medicine, careful planning and strategy are essential to minimize the risk of unfavorable outcomes (Galęba and Marcinkowski 2015).

This brings us to the final issue of medical malpractice and negligence which pretty much covers several factors mentioned earlier and the strategy involved when faced with a botched aesthetic medical procedure. The ethical principle of “non-maleficence” requires physicians to avoid causing harm to patients. While risk is inherent to all surgical procedures, it becomes notably pronounced in aesthetic medicine due to the field’s less stringent regulations. Instances of infection or surgical complications may occur, particularly when procedures are carried out by unqualified personnel. In regions like Hong Kong, aesthetic medicine is not even recognized as a speciality, thereby allowing general practitioners to perform these procedures without further training, leading to negligence (Burd 2021). So, what should stakeholders do in the case of negligence? Patients and their families are faced with grim reality of dealing with complications or irreversible damage. Physicians, on the other hand, must navigate the complex waters of legal responsibility while also dealing with challenging patient expectations.

• For patients and families: Seek immediate medical attention and consider legal options.

• For physicians: Implement rigorous informed consent procedures and maintain detailed medical records to protect their professional rights.

• For clinics: Establish strict guidelines for follow-ups and emergency procedures.

Actionable Recommendations for Aesthetic Medicine

It is important to assess and evaluate the quality of healthcare services every now and then to identify its gaps and make recommendations necessary to improve them for the sake of patients. In 2013, the UK presented the Keogh Report, which received significant media attention, and which was led by Sir Bruce Keogh, who was the Medical Director of the National Health Service (NHS) at the time (National Health Services 2013a). The review commissioned to assess the quality of care and treatment at 14 NHS hospital trusts, which had high mortality rates, hoping to identify the cause so that improvements could be made. It highlighted lapses in the quality and safety standards, ethical considerations emphasizing patient-centered care, and the need for accountability of different levels, which calls for regulatory and policy changes. Ultimately, such actions heightens the quality of healthcare services enhancing reputations directly impacting the medical tourism industry. Many countries have published similar reports, such as To Err is Human (National Academies of Sciences, Engineering, and Medicine 2000) in the USA, The Francis Report (National Health Services 2013b) in the UK, the Accreditation Canada’s Qmentum Program, reports by the World Health Organization, and finally, the National Healthcare Quality Report, which is common in several countries. Although these reports may not explicitly address aesthetic medicine or medical tourism, but they do address overlapping issues, some of which are the indirect ramifications of these sectors such as quality of healthcare, sound governance ensuring ethical practices. In the case of UK, the “Cosmetic procedures: ethical issues” report in 2017 was an official review of aesthetic medicine or cosmetic medicine aspects compelling for attention and improvements which included several key recommendation that should be considered by other countries given its benefits (Nuffield Council on Bioethics 2017).

Legislation and Oversight

The unique nature of aesthetic medicine, particularly its shift from therapeutic intervention to aesthetic enhancement, calls for specialized governance. Formulating a distinct act or legislation with provisions pertaining to aesthetic medicine and medical tourism may be ideal. However, given the existing overlapping acts and laws—such as Medical Act, Medical Devices Act, Human Tissue Act, and Private Healthcare Act—enacting another exclusively for aesthetic medicine may not be cost-effective. While laws that define the legal and ethical responsibilities of aesthetic medicine practitioners are ideal, comprehensive guidelines that harmonize existing policies and legislation can also be valuable. Therefore, it may be worthwhile to revisit existing acts and laws, to embed provisions specifically related to aesthetic medicine where appropriate. For instance, the Medical Devices Act could mandate the registration of all fillers, botox, and implants used in aesthetic medicine as prescription-only-medical devices. Consequently, only those substances listed or found in an official registry would be deemed legal and of acceptable quality, thereby enhancing patient safety preventing illegally procured fillers and implants from being used (Nuffield Council On Bioethics 2017).

Policymakers should consider developing guidelines specific to aesthetic medicine to protect the rights and welfare of both patients and physicians, especially if such guidelines do not already exist. These guidelines should clearly outline qualifications of the experts performing the procedures. They should also address the additional risks associated with undergoing multiple procedures simultaneously and require a more detailed, procedure-specific informed consent. Further, guidelines should stipulate postoperative care protocols, approvals for advertisements, and procedure for handling violations and negligence. Regulatory bodies may also benefit from establishing an oversight committee or inter-speciality panel tasked with regularly reviewing and updating of aesthetic medicine guidelines. This committee could set standards for cosmetic surgery, training, and certification, as well as overall regulations.

Specialized Training and Qualifications

Within these specialized guidelines, qualifications, training, and certifications required for practitioners in aesthetic medicine should be clearly defined. Anyone planning to enter this field and perform such procedures should, first and foremost, be medically trained (i.e., hold a medical degree). Additionally, they should acquire specialized training and certification in aesthetic medicine or cosmetic medicine to ensure adequate knowledge and skills in performing these procedures. This will help guarantee that the anesthesia doses and intricate procedural steps, such as the depth of fillers or botox injections, are administered correctly and not done haphazardly. In line with the Health Education England’s (HEE’s) mandate to establish appropriate accreditation qualifications for the providers of surgical and non-surgical interventions, this approach should be viewed as a step in the right direction. If educational program on aesthetic medicine and cosmetic medicine exists, they should conform to these standards and accreditations. To further enhance patient safety, regulators should establish a publicly accessible national or international database or registry for verifying practitioners’ credentials. This step will not only provide an additional layer of assurance for patients but also help to reduce or even eliminate the operation of illegal clinics, as their credentials will be easily verifiable.

Advertising and a Platform for Complaint

Advertising for any aesthetic and cosmetic medicine procedures should adhere to principles of truthfulness, transparency, and patient safety. The guidelines should ensure that promotional materials clearly describe the qualifications of the medical practitioners, as well as the risks, benefits, and alternatives of the procedures being offered. “Before and after” photos, if used, should be realistic, not digitally altered, and must accurately represent potential outcomes. Any claims made in advertisements should be substantiated by scientific evidence to avoid misleading the public. It is also essential to avoid making absolute guarantees about results, as individual experiences may vary. The advertising material should never exploit patients’ insecurities or promise unrealistic outcomes, such as “eternal youth,” to prevent creating false expectations. Furthermore, advertisements should not minimize or omit significant risks associated with the procedures. If special offers or discounts are advertised, they must be presented in a manner that does not pressure or rush the patient into deciding. Ethical considerations should be at the forefront, ensuring that ads do not target vulnerable populations, such as minors, who may not fully grasp the implications and risks involved in aesthetic medicine procedures. The oversight committee or inter-speciality panel tasked with regularly reviewing and updating of guidelines should also adopt the role of reviewing all forms of advertisements for approvals, within appropriate time frame to ensure all advertisements are within ethical boundaries and those not bearing the approval stamp will be fined and penalized. In case of any unethical advertising including inaccurate information, no mentions of risks and benefits are altered. “Before and after” photos, if used, and finally inaccurate represent potential outcomes. It is also important to educate public and potential patients to make complaints about advertisements that are in violation of ethical code of practice (Collier 2018; Nuffield Council On Bioethics 2017).

Comprehensive Informed Consent Procedure and Postoperative Care

New regulations should include standardized forms for informed consent in aesthetic medicine that accounts for both procedural details and unique non-medical considerations inherent to elective procedures. This would empower patients to make informed decisions. In UK, the Royal College of Surgeon (RCS) Inter-speciality Committee of Cosmetic Surgery has recommended a multi-stage informed consent process for cosmetic procedures (Nuffield Council on Bioethics 2017). Consent should be obtained by the surgeon performing the procedure to ensure a shared understanding of expected outcomes and limitation between patients and practitioners. This approach also allows patients time to digest information, think carefully, and seek clarification on any uncertainties. For non-surgical procedures, providers must maintain a record of consent. Initially, informed consent should be secured when specific details about the procedure, its risks, and outcomes are discussed; a second consent should be obtained on the day of the procedure as a best practice to confirm patients still wished to proceed.

Mandatory postoperative care and follow-up should apply to all patients, regardless of their residency status. This is particularly important for tourists traveling for procedures. Generally, postoperative care promotes patients’ recovery and includes pain management, wound care, oxygenation support, cardiovascular stabilization, fluid balance maintenance, and complication prevention (Nuffield Council on Bioethics 2017). Given that anesthesia is administered in these surgeries, the standard for aesthetic or cosmetic procedures should be no different. For example, patients undergoing multiple procedures like liposuction and tummy tuck should receive in-hospital care for at least 24 hours before discharge. Follow-up appointments should be scheduled within three days to a week to monitor healing and identify any complications or undesired outcome. For tourists, surgeons or the providers should offer postoperative care details that a general practitioner in the patient’s home country can oversee. In cases where in-person visits are impractical, telemedicine could serve as an alternative for postoperative care, thereby ensuring fewer surprises and more predictable recovery outcomes. Currently, a majority of existing guidelines lack such provisions, making it a critical element that should be included.

Handling Medical Malpractice and Negligence

It is essential for healthcare professionals, particularly those in aesthetic or cosmetic medicine, to be well-versed in relevant laws and ethical principles. This should include an understanding of informed consent, mental capacity laws, and medical negligence principles. For practitioners who have undergone additional training and acquired specialized qualifications in aesthetic and cosmetic medicine, this knowledge is generally integrated into their educational curriculum. Therefore, surgeons and other practitioners conducting these procedures are equipped with the necessary legal and ethical understanding, enabling them to make informed decisions specific to the procedures they perform. Guidelines should clarify which medical laws and ethics are particularly relevant to aesthetic and cosmetic medicine, as well as any unique considerations in this field. These guidelines should also mandate a transparent reporting process for complications and adverse events, benefiting both the medical community and potential patients. This reporting process could also be integrated into insurance requirements, protecting both practitioners and patients from unlawful claims and liabilities. Malpractice insurance should be mandated for all practitioners in aesthetic medicine to provide financial protection for patients in cases of negligence.

In instances of negligence, patients have the right to seek compensation under contract law, the tort of negligence, and the provider’s policies if they suffer from medical complications or are dissatisfied with the outcome. Patients should not be expected to pay for additional treatment required due to medical complications arising from their procedure. While some providers offer 24 hour emergency cover and rapid response for postoperative care, not all have the necessary facilities to handle life-threatening situations. In such cases, the provider could refer the patient to an emergency healthcare provider and reimburse the costs, as a show of good faith and commitment to delivering the best possible care to their patients (Nuffield Council on Bioethics 2017).

Finally, clinics operating outside the conventional healthcare industry as beauty or wellness boutiques should not be allowed to function in order to prevent unqualified individuals from administering treatments. Such establishments should be required to register as proper “healthcare clinics” offering aesthetic or cosmetic medicine procedures, carried out by qualified medical practitioners. However, there may be unique cases where such boutiques could be permitted to operate. This would be contingent upon them offering only non-invasive procedures, as classified in existing guidelines, and having qualified medical practitioners either as partners or as the individuals performing the procedures (Campbell 2023; The Retreat Clinic 2021).

Public Education

Finally, authorities and regulatory bodies should initiate public awareness campaigns concerning the risks associated with aesthetic medical procedures. Such campaigns could span various media platforms, including radio, television, and social media, and should address not only specific procedures but also their risks and benefits, expected and potential undesired outcomes, and the process of informed consent and postoperative care. This approach would serve three primary purposes: first, to inform patients and their families about the standard protocols; second, to enable them to recognize deviations from these protocols; and third, to guide them on appropriate actions in cases of negligence. A centralized, easily accessible repository should be established, featuring verified information about various aesthetic and cosmetic procedures, the informed consent process, and steps to take in the event of undesired outcomes. This will allow the public to verify information and familiarize themselves with the overall procedure. Additionally, public school curricula should include mandatory lessons advocating body positivity (Nuffield Council on Bioethics 2017; Widdows 2020).

Conclusion

Aesthetic medicine has emerged as not merely a niche but as a crucial segment within the broader medical landscape. Its increasing relevance transcends the boundaries of cosmetic enhancement, offering significant contributions to mental health, the treatment of various medical conditions, and overall well-being. Given its multifaceted impact, aesthetic medicine should no longer be relegated to the sidelines. It deserves recognition as either a subspeciality or a distinct field of specialization, akin to other medical disciplines. This formal recognition would provide practitioners with a more tangible sense of qualification and legitimacy and should be approached with the same gravitas as other areas of medicine.

However, despite its significance, this study underscores that the field of aesthetic medicine faces substantial challenges, particularly in the realm of ethical and regulatory oversight. Concerns span a wide array, from the qualifications of practitioners to frequent violations of foundational ethical principles like non-maleficence, beneficence, justice, and autonomy. A comparative analysis of regulations in selected Asian countries, including India, Malaysia, Singapore, South Korea, and Thailand, reveals that existing laws are insufficient and ineffective for governing this complex field. Traditional codes of practice and laws, designed primarily for therapeutic medicine, fall short of addressing the unique ethical and practical challenges of aesthetic medicine.

Therefore, immediate action is necessary to address these challenges. Policymakers must reassess and reform the existing regulatory framework to develop a more effective, realistic, and practical set of regulations. Comprehensive legislation should integrate provisions tailored to aesthetic medicine with existing medical laws. Specialized training and certification for practitioners, ethical advertising guidelines, robust informed consent procedures, stringent postoperative care, and public education campaigns form key pillars of a multi-pronged governance strategy. The necessity for stringent oversight extends to the burgeoning sector of medical tourism, where aesthetic medicine plays a significant role. Here, governance should ensure equitable access and quality of care, irrespective of geographical boundaries.

In conclusion, a balanced and comprehensive governance approach is essential for safeguarding the interests of all stakeholders. This not only serves to enhance the standards and ethics in aesthetic medicine and medical tourism but also contributes to their sustainable growth. Such governance measures are imperative for maintaining public trust, ensuring patient safety, and upholding the integrity of the medical community as a whole. By adopting a nuanced and inclusive approach, we can cultivate an ethical and advanced environment conducive to the sustainable growth of aesthetic medicine and related sectors.

Data Availability

The data that support the findings of this study are derived from public domain resources and official government portals.

Declarations

Ethics Approval

Not applicable.

Conflict of Interest

The author declares no competing interests.